A health maintenance organization (HMO) contracts with select doctors and hospitals to be a health care provider for its members. Enrollees in the HMO receive services for a fixed premium paid in advance.
They include the following: nursing and physical therapy, occupational therapy, speech therapy, medical social work, nutritional consultation, services of a home health aide, and use of durable medical equipment and supplies. Which of the following statements pertaining to health maintenance organizations (HMOs) is CORRECT?
-X-rays, lab, and other diagnostic tests -Maternity care -Drugs, medications, anesthesia -Physical, radiation, and inhalation therapy Capitation The payment method used by HMOs HMO pays in-network health care providers a fixed amount for each member of the HMO Pay per member, not per service Open Enrollment
HMOs have become a competitive alternative for health care providers and those concerned with reducing costs. Co-payments were introduced by HMOs and are flat dollar fees paid per visit by subscribers. Managed care cost savings include well checks, annual visits, routine visits, wellness plans, smoking cessation, and weight loss programs.
Federal law requires employers with 5 or more employees to implement an HMO plan for health care coverage. Explanation. An HMO offers health care services to its subscribers and emphasizes preventive health care by providing full benefits for routine physical check-ups, immunizations, and the like.
The HMO Act of 1973 specified requirements that must be met for an HMO to receive federal qualification. For example, federally qualified HMOs must provide basic health care services and charge a community rate.
A) a POS plan utilizes a gatekeeper, while a PPO does not. B) a PPO allows the individual to use any service provider, while a POS plan requires the individual to use only preselected providers.
A limitation for new subscribers is if their current physician does not contract with the HMO, then the subscriber must choose a new doctor from a listing of those providers who are under contract.
HMOs stress preventive care to reduce the number of unnecessary hospital admissions and duplication of services.
A) A PPO is a group of health care providers, such as doctors, hospitals, and ambulatory health care organizations, that contracts with a group to provide their services. B) Employers, insurance companies, and other health insurance benefit providers are typical groups that contract with PPOs.
Home health care refers to services provided by a licensed home health agency to an insured in her place of residence. These services must be prescribed by the person's attending physician as part of a written plan of care. Disability insurers must make benefits for home health care available under group insurance policies.
The roots of HMOs and PPOs can be traced back as far as the early twentieth century, but it wasn’t until 1973 when President Richard Nixon signed the Health Maintenance Organization Act, encouraging and even requiring select businesses to include HMOs as an option for employee healthcare plans. 16.
Another difference between an HMO and a PPO is the amount of legwork it takes on both ends. With an HMO, patients do not need to file a claim because the insurance company pays the healthcare provider directly.
The history of PPOs can also be traced back to the Health Maintenance Organization Act. Once HMOs were born, insurance companies saw an opportunity to provide patients with more flexibility while giving themselves better control over medical costs. Hence, PPOs were introduced. PPOs rose to popularity among large corporations with many offices spread throughout the country, as a comprehensive PPO plan allows for greater geographical flexibility among the many employees.
An HMO offers no coverage outside of the network, but patients typically enjoy lower premiums. For example, the average 2021 monthly premium for an HMO is $427 ($5,124 annually), compared to a monthly average of $517 for a PPO ($5,628 annually). 7. Generally, the out-of-pocket costs for an HMO may be lower than those of a PPO.
More people are enrolled in PPO plans than HMOs. In 2020, 47% of covered workers enrolled in an employer-supplied health insurance plan chose a PPO, compared to just 13% of covered workers who chose an HMO.
If a plan is offered on any Affordable Care Act (ACA) marketplace, it is required to cover preventive care (such as checkups, physicals, or immunizations) as well as emergency services and maternity care.
Health Insurance and Provider Networks. A network is a group of healthcare providers that have contracted with an insurance company to offer discounted services. 3 These networks typically include general physicians and specialists, such as dermatologists and chiropractors.