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