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Managed Care Health Insurance represents systems and techniques used to control the use of health care services.

Includes a review of medical necessity, incentives to use certain providers, and case management. The body of clinical, financial and organizational activities designed to ensure the provision of appropriate health care services in a cost-efficient manner.

Managed care techniques are most often practiced by organizations and professionals that assume risk

for a defined population (e.g., health maintenance organizations) but this is not always the case. Managed care is a broad term and encompasses many different types of organizations, payment mechanisms, review mechanisms and collaborations. Managed care is sometimes used as a general term for the activity of organizing doctors, hospitals, and other providers into groups in order to enhance the quality and cost-effectiveness of health care.

Managed care Health Insurance plans fall into 3 basic types plans:

* HMO
* PPO
* POS

A common trait among managed care plans is the incentive (usually, a lower premium) for the insured to stay within a specified network of health care providers.

Health Maintenance Organizations (HMOs)

HMOs provide medical treatment on a prepaid basis, which means that HMO members pay a fixed monthly fee, regardless of how much medical care is needed in a time period (usually a monthly basis). In return for this fee, most HMOs provide a wide variety of medical services, from office visits to hospitalization and surgery. There are exceptions but most HMO members must receive their medical treatment from those within the network.

Preferred Provider Organizations (PPOs)

A PPO is made up of doctors and or hospitals that provide medical service only to a specific group. Rather than prepaying for medical care, PPO members pay for services as they are provided. The PPO sponsor (usually an employer or insurance company) usually reimburses the member for the cost of the treatment, minus any co-payment fee. In some cases, the doctor may submit the bill directly to the insurance company for payment. The insurer then pays the covered amount directly to the health care provider, and the member pays his or her co-payment amount. The price for each type of service is negotiated in advance by the health care providers and the PPO sponsor(s).

Point Of Service (POS) plans

A point of service plan is a type of system where you pay no deductible and usually only a small co-payment when you use a health care provider within your network. You also must choose a primary care physician who is responsible for all referrals within the POS network. If you choose to go outside of the network for health care, you will likely be subject to a deductible, and your co-payment will be a percentage of the physicians charges.

Article by: Insurance Finder

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