Understanding Managed Care Organizations
Things used to be very simple, You were sick, you went to a doctor and your insurance plan paid for it. Today, most of us are covered by a whole new breed of health insurance managed care plans. Created to lower the overall costs of healthcare, managed care organizations have been around since the mid-80s.
HMOs, or Health Maintenance Organizations, are still the most common form of managed care in the Northeast, Northwest, and Minnesota. Others include Preferred Provider Organizations or PPOs, Independent Practice Associations or IPAs and POS or Point-of-Service Plans.
WellPoint the nations largest provider which oowns such companies as UniCare, and Blue Cross of California is a prime example of a managed care company.
Regardless of which kind of managed care you've been considering, reading up on them first helps you choose the right one. This quick overview is designed to lend you a hand as you explore the world of managed health care.
Same Goals, Different Health Insurance Plans
New brands of managed care are set up all the time but they all generally aim to combine insurance benefits with health care services in a way that reduces costs. The assortment of managed care plans available to you can be defined based on the choices they provide their members.
Health Maintenance Organizations: The HMO is the original managed care plan. As a member, you're required to select a primary care physician who is responsible for coordinating your health care (prescription and specialist referrals, etc.). Whenever you receive medical care, youıre responsible for a co-payment. HMOs carry a fixed charge of $10 to $15 per office visit and a charge of around $100 for hospital stays.
The HMO pioneer was Group Health of Washington and Minnesota and the programs still thrive in those states because consumers are used to them, and the right infrastructure exists to support them.
In exchange for that relatively low out-of-pocket rate, as an HMO member all your care must be from inside the organization's network of care providers. You also won't have access to specialists unless you've first obtained a referral from your primary care physician.
Once again, in the state of Illinois HMO's have proven to be unpopular and unprofitable, so you are not going to find as many choices even as a group.
Point of Service Plans: The POS brand of managed care shares a few features with HMOs and others with traditional insurance plans. If you seek care inside your POS plan's network, you're only responsible for a relatively modest co-payment. If you receive care from outside your POS network, you have to pay your coinsurance and your annual deductible.
BCBSIL offers Select Advantage plans which are a versatile example of this model.
In general, POS plans offer you flexibility with the lower rates of managed care. POS plans also tend to include the same preventive care coverage as an HMO.
Preferred Provider Organizations: Your PPO health plan gives you access to a full range of doctors, specialists and hospitals that have all agreed to reduced fees. You wonıt have to give up access to outside providers as you would with an HMO, but you will have to pay more to see an outside health care provider.
PPOs offer more flexibility than managed care. You're free to visit any specialist you would like without a referral from your primary care physician (but as with an HMO, you will have to choose one). It is fair to say you will be able to seek out any service you need directly. It will cost more, but it will also be convenient.
PPO's are king in Illinois, and most of the Midwest because they offer the most important facet in your healthcare decison, the ability to visit any provider you would like whether thay are in or out of network. Consumers appreciate freedom of choice above anything else.
Prevention and Wellness
A common focus of all the managed care plans you're considering is prevention. The majority of managed care organizations sponsor and even encourage preventative health programs designed to help you lose weight, stop smoking, etc. Keeping you healthy helps lower their costs in the long run, good for you, and good for them.
Look for a PPO plans such as UniCare or BCBSIL which included a Wellness benefit each year. Typical amounts are $300 to $500 alloted per person, per year.
You can prevent paying too much for insurance by taking the time to read up on your health insurance alternatives. Getting an effective and low cost health plan is the only way to ensure your family continues to be well cared for if you unexpectedly fall ill or are injured.
Do the research -- it definitely makes a difference down the road, and give us a call at 800-391-7469 if you have any questions.
| 
l