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Health and Medical Insurance - Comparing Managed Care Health Plans

Health insurance plans have been forced require referral from the primary care
to take action to contain costs of provider. This cost containment strategy
quality health care delivery as health is intended to avoid duplication of
care costs have skyrocketed. Health services (for example, the cardiologist
insurance premiums, deductibles and ordering tests that have already been
co-pays have steadily increased, and done by the PCP, or a sprained ankle
health insurance companies have being referred to an orthopedic) and
implemented certain strategies for avoid unnecessary specialist referrals,
reducing health care costs. "Managed tests and/or procedures.
care" describes a group of stratgies HMO and PPO plans also contain costs by
aimed at reducing the costs of health requiring prior approval, prior
care for health insurance companies. authorization, or pre-certification for
There are two basic types of managed care many elective hospital admissions,
plans; health maintenance organizations, surgeries, costly tests and imaging
or HMOs, and preferred provider procedures, durable medical equipment and
organizations, or PPOs. So which health prescription drugs. When such services
plan is best? How do you choose what are required, the provider must submit a
type of health insurance best suits the request to the health insurance plan
health care needs of you and your family? review department, along with medical
Both HMOs and PPOs contain costs by records that justify the service. The
contracting with health providers for request is reviewed by the health
reduced rate on health care services for insurance company to determine whether
its' members, often as much as 60%. One the services are justified as "medically
important difference between HMOs and necessary" according to the health plan
PPOs is that PPOs often will cover the policy and guidelines. Review is usually
costs of care when the provider is out of performed by licensed nurses, and, if the
their network, but usually at a reduced reviewer agrees that the service is
rate. On the other hand, most HMOs offer necessary, approval is given and the
no coverage for health care services for service will be covered by the health
out-of-network providers. insurance plan.
Both HMO and PPOs also control health As health care costs continue to rise,
care costs by use of a gateway, or many indemnity health insurance plans, or
primary care provider (PCP). Health "fee for service" plans are being forced
insurance plan members are assigned (or to adopt some managed care strategies in
select) a primary care practitioner order to provide quality health care and
(physician, physician assistant, or nurse keep health insurance premiums
practitioner). usually a family affordable. And as long as health care
practitioner or internal medicine doctor costs continue to rise, the distinctions
for adult members or a pediatrician or among PPO, HMO, FFS and other health
family care practitioner for childern. insurance plans will become blurred.
The primary care provider is responsible Rest assured, however, that managed
for coordianting health delivery for plan health care is here to stay.
members. Care by specialist physicians




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