The Four Types of Managed Health Care Plans Are: A Guide

Managed health care plans can be overwhelming, but understanding the basics can make a big difference. There are four main types of managed health care plans.

Each type of plan has its own unique features and benefits. For example, Health Maintenance Organizations (HMOs) typically require members to choose a primary care physician and get referrals to see specialists.

HMOs are often the most cost-effective option, with lower premiums and out-of-pocket costs. However, they may have limited provider networks and restrictions on out-of-network care.

Preferred Provider Organizations (PPOs) offer more flexibility than HMOs, allowing members to see any provider without a referral. This comes at a higher premium, but with greater freedom to choose healthcare providers.

There are several types of network-based managed care programs, ranging from more restrictive to less restrictive. Managed care in indemnity insurance plans, also known as "managed indemnity" plans, incorporates features like precertification for non-emergency hospital admissions and utilization reviews.

A health maintenance organization (HMO) is a coordinated delivery system that combines financing and delivery of health care for enrollees. Each member is assigned a "gatekeeper", a primary care physician responsible for their overall care.

Here are the main types of managed care plans:

Managed indemnity plans and HMOs are two of the main types of managed care plans, offering different levels of restriction and flexibility.

A Health Maintenance Organization (HMO) is a type of network-based managed care program.

HMOs were proposed in the 1960s by Dr. Paul Elwood and became law in 1973 as the Health Maintenance Organization Act.

A federally-qualified HMO allows members access to a panel of employed physicians or a network of doctors and facilities in exchange for a subscriber fee.

HMOs are licensed at the state level under a certificate of authority rather than an insurance license.

Each HMO member is assigned a "gatekeeper", a primary care physician responsible for the overall care of members assigned.

Specialty services require a specific referral from the primary care physician to the specialist.

Non-emergency hospital admissions also require specific pre-authorization by the primary care physician.

Services are not covered if performed by a provider not an employee of or specifically approved by the HMO unless it defines the situation to be an emergency.

HMOs have been protected by federal law from malpractice litigation since the 1980s under the ERISA Act.

This protection applies to HMOs administering benefits through private employer health plans.

An Independent Physician Association (IPA) is a type of organization that contracts with a group of physicians to provide service to a managed care plan's members.

The physicians in an IPA are usually paid on a capitation basis, which means they receive a set amount for each enrolled person assigned to them, regardless of whether that person seeks care.

This arrangement allows individual doctors or groups to sign contracts with multiple managed care plans, giving them flexibility in their business relationships.

Physicians who participate in IPAs often also serve patients who are not part of a managed care plan, providing them with a broader range of options for their care.

Private Fee-for-Service (PFFS) plans are a traditional type of health care policy where insurance companies pay medical staff fees for each service provided to an insured patient.

These plans offer a wide choice of doctors and hospitals, giving you the freedom to choose your own medical team.

PFFS coverage falls into two categories: Basic and Major Medical Protection. Basic protection covers the costs of a hospital room, hospital services, care and supplies, cost of surgery in or out of hospital, and doctor visits.

Major Medical Protection covers costs of serious illnesses and injuries that require long-term treatment and rehabilitation.

Indemnity insurance plans have evolved to incorporate managed care features, often referred to as "managed indemnity" plans.

Some of these plans now require precertification for non-emergency hospital admissions, which is a managed care feature.

This means that even in traditional indemnity insurance plans, some level of managed care is being implemented.

Managed care features like utilization reviews are also becoming more common in these plans.

These features help ensure that healthcare services are used efficiently and effectively.

Some examples of managed care features in indemnity insurance plans include:

These features aim to improve health care quality while controlling costs.

Illinois Managed Care is a program offered by the Illinois Department of Healthcare and Family Services (HFS).

The Illinois Department of Healthcare and Family Services (HFS) website is the official source for information about Managed Care Programs in Illinois.

Welcome to the Managed Care section of the Illinois Department of Healthcare and Family Services (HFS) website, where you can find information about the programs.

Managed Care Programs in Illinois are designed to provide coordinated and cost-effective healthcare services to eligible individuals.

You can find more information about Illinois Managed Care on the HFS website.

Other Managed Care Arrangements offer a range of options beyond the traditional HMO and PPO plans.

Accountable Care Organizations (ACOs) are groups of healthcare providers who work together to coordinate care for patients with chronic conditions, improving health outcomes and reducing costs.

In a Capitated Managed Care Arrangement, a single entity contracts with a healthcare provider to manage the care of a specific population, often with a fixed budget.

Health Maintenance Organizations (HMOs) are a type of managed care plan that requires patients to receive care from a specific network of providers, often with lower out-of-pocket costs.

Preferred Provider Organizations (PPOs) allow patients to choose from a network of providers, but also offer out-of-network coverage for a fee.

Some managed care plans offer a Point of Service (POS) option, which allows patients to choose between HMO and PPO coverage at the time of service.

Managed care plans are evolving to include features from traditional insurance plans. Some of these plans, known as "managed indemnity" plans, incorporate precertification for non-emergency hospital admissions and utilization reviews.

These plans aim to improve health care quality. They do this by reviewing and managing the use of medical services.

Managed care features are being added to traditional insurance plans. This is done to control costs and improve health outcomes.

Some examples of managed care features include precertification and utilization reviews. These features help ensure that medical services are necessary and provided in a cost-effective manner.

Managed care plans are designed to improve health care quality and reduce costs. They do this by managing the use of medical services and reviewing the necessity of treatments.