Managed Care Continuum
Managed health care plans are often described as continuum models. Continuum models are used to describe gradual transition with sudden changes such as managed health care plans. These plans are involved in models consisting of cost and quality. There are four main healthcare plans that emphasize on continuum of managed care including service plans, POS, HMO, PPO and CDHP plans. Each of these health plans are consisted of different features, structures and guidelines that make them unique and effective in their own way. Traditional health insurance is the first type of managed care mentioned in continuum model. It includes indemnity insurance and service plan. The recent constant rises of premium have caused the traditional insurance to shrink
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Also, a contract is only offered if the providers meet the criteria of credentials and practice pattern analysis. Moreover, precertification and case management are mandatory of PPO. The key difference between service plan and PPO is that the penalty results from failing to comply with the program will be counted toward the provider instead of the subscriber. Benefits are also limited if subscribers seek care from provider that is not in PPO network. For example, member can receive up to 80 percent of allowed charges from network provider, while one can only receive 60 percent level with not in network provider. PPO can also be divided into two categories: risk bearing and non-risk bearing. The risk-bearing PPO will combine insurance/payment that correlate with the network provider. On the other hand, the non-risk-bearing PPO will focus only on network management. Generally, PPO is usually less expensive than service plan but still more expensive than HMOs …show more content…
Open-access HMOs are similar to PPOs, members can see a PCP or specialist but there is a difference in cost-sharing between specialist and PCP for provided care. Moreover, most open-access HMOs provide low benefits or no benefits for out-of-service providers and non-emergency care. The second HMO is called open-panel plans, which compose of two categories: independent practice association and direct contract models. The IPA will act as a third party and contract with private physicians to provide care to HMO members; while HMO will directly contracts with private physicians and pay them directly for provided care in the direct contract models. Open-panel plan is far more common than closed-panel plan. In the closed-panel plans, the members choose their primary HMO facility to receive continuity of care and they can see the PCP or specialist in the facility. There are two categories in the closed-panel plans: group model and staff model. The HMO will contract with a group of physicians to provide services to members in the group model and pay them with negotiated capitation. In contrast, the HMO will contract with the physicians directly in the staff model but this plan is almost instinct nowadays. In the mixed-model plans, HMOs basically adopt new model types to attract consumers and one of the most common forms is direct contract
Also, a contract is only offered if the providers meet the criteria of credentials and practice pattern analysis. Moreover, precertification and case management are mandatory of PPO. The key difference between service plan and PPO is that the penalty results from failing to comply with the program will be counted toward the provider instead of the subscriber. Benefits are also limited if subscribers seek care from provider that is not in PPO network. For example, member can receive up to 80 percent of allowed charges from network provider, while one can only receive 60 percent level with not in network provider. PPO can also be divided into two categories: risk bearing and non-risk bearing. The risk-bearing PPO will combine insurance/payment that correlate with the network provider. On the other hand, the non-risk-bearing PPO will focus only on network management. Generally, PPO is usually less expensive than service plan but still more expensive than HMOs …show more content…
Open-access HMOs are similar to PPOs, members can see a PCP or specialist but there is a difference in cost-sharing between specialist and PCP for provided care. Moreover, most open-access HMOs provide low benefits or no benefits for out-of-service providers and non-emergency care. The second HMO is called open-panel plans, which compose of two categories: independent practice association and direct contract models. The IPA will act as a third party and contract with private physicians to provide care to HMO members; while HMO will directly contracts with private physicians and pay them directly for provided care in the direct contract models. Open-panel plan is far more common than closed-panel plan. In the closed-panel plans, the members choose their primary HMO facility to receive continuity of care and they can see the PCP or specialist in the facility. There are two categories in the closed-panel plans: group model and staff model. The HMO will contract with a group of physicians to provide services to members in the group model and pay them with negotiated capitation. In contrast, the HMO will contract with the physicians directly in the staff model but this plan is almost instinct nowadays. In the mixed-model plans, HMOs basically adopt new model types to attract consumers and one of the most common forms is direct contract