Posts Tagged ‘Plan’
A Health Maintenance Organization (HMO) is a type of managed health care plan. An insurance policy is combined with a network of medical providers like doctor’s, hospitals, and pharmacies. The network providers agree to the network policies for providing care and setting prices. In return, network providers get added to the list which should provide them with a steady stream of patients.
Because of this arrangement, the medical provider can keep attracting patients, and perhaps save some costs associated with that activity. A doctor’s office, for instance, that can count on a steady stream of regular patients, may be able to charge less for an appointment than a doctor’s office without a full schedule.
The network gets to manage costs and care, and that way they can contain costs and improve efficiency for themselves, and for their covered clients.
The health plan participants must use the network providers in order to have their health care covered in most cases. This restriction also allows the health care plan to manage costs. Exceptions are made to the network coverage policy in the case of an emergency. Sometimes, if a particular medically needed service is not provided by the HMO, an exception will be made to the network restriction as well. In any case, if the insured person needs to seek care outside the network, in a non-emergency situation, the service should be pre-approved, in writing, by the health plan’s administrator.
HMO plans work well for many people. Most of us are used to choosing a primary care doctor from a list that our insurance company provides us. We are also used to accepting that professional’s advice when we need to see a specialist. For people that live in an area where an HMO has a large network of medical providers, it is usually no problem to find quality care for a variety of medical needs.
Insured people enjoy lower premiums and copays in return for accepting tighter network restrictions and managed health care. In addition, patients usually do not have to complete much paperwork as all forms are handled by the doctor’s office and insurance company.
However, people who do not live by a large and active network may not be satisfied with their available privders. In particular, people who need to seek specialized medical services may have to travel or have trouble obtaining a referral to a specialist outside of the local medical provider network. If a situation comes up where an HMO participant wants to see a particular doctor who does not work with the network, they may have to pay the full cost of the appointment and associated costs if they cannot get an exception approved.
The health plan that will satisfy you, and your family really depends upon many factors. Your age, gneral health, and the available plans in your area will affect your choice. But for those who live close to a large network of providers, and who usually only need routine or typical medical care, an HMO can be a great choice.
There are many facets to the world of mental health, especially when it comes to health insurance and finding adequate coverage for a variety of afflictions and disorders. We’ve put together some answers to some of the more common questions revolving around these topics for you below.
Do most health plans include mental health coverage? The answer, simply put, is yes. The vast majority of insurers and health plans cover at least a limited amount of mental health care.
According to a recent employer survey published in the journal Health Affairs:
•91 percent of small firms (10-499 employees) and 99 percent of large firms offer mental health and substance abuse coverage in their most used medical plans.
•Mental health and substance abuse coverage was included in 87 percent of indemnity plans, 88 percent of HMOs, 97 percent of Point of Service (POS) plans and 93 percent of Preferred Provider Organizations (PPOs).
It is commonly acknowledged today, in 2006, that most employees who have employer-based health insurance have access to mental health coverage, and many of the employees who don’t have coverage have simply chosen not to join an employer’s plan that includes mental health services.
Does mental health coverage cost more? Yes, this is generally the case. There are limits to mental health coverage and the reason why most employers impose limits is due to cost. Estimates vary widely of how much more mental health coverage costs. Here are some results from some studies:
•A 1998 study sponsored by National Advisory Mental Health Council (NAMHC) Parity Workgroup, a division of the federal National Institute of Mental Health, estimated that mental health services would add less than 1 percent to the cost of a health insurance policy for an HMO.
•A 1998 study by Mathematica estimated a 3.6 percent increase across all plans, with a range of 0.6 percent increase for HMOs up to a 5 percent increase for fee-for-service plans.
•A 1997 analysis by the actuarial firm Milliman & Robertson for the National Center for Policy Analysis, examining the cost of a typical mental health mandate (not specific legislation), concluded that mental health services parity legislation tends to drive up costs by 5 percent to 10 percent.
With regard to mental insurance in general, how do insurance companies treat mental illness? Insurance companies tend to be somewhat wary of mental health claims due to the increase of fraudulent claims. When Medicare looked for fraud in the community mental health centers last year, it barred 80 of them in nine states from participating in the program.
The Health Care Financing Administration (HCFA), which administers Medicare, knew something was amiss when the average yearly cost for each senior getting mental health services jumped from $1,642 in 1993 to more than $10,000 by 1997.
Medicare administrator Nancy-Ann DeParle contended at the time that 90 percent of the patients had no mental illness serious enough to qualify for special treatment.
That being said, it’s straightforward to understand why there is trepidation on the part of health insurance providers.
What mental conditions are typically covered, and not covered by health plans? Generally speaking, a health plan pays for only those services included in the plan’s list of covered services. In the case of mental health services, inpatient and outpatient treatment are most often covered by health plans.
However, there is a continuum of services between inpatient (mental health clinic) and outpatient care that effectively treat many mental disorders and are often more cost-effective than inpatient care at a mental health clinic.
These intermediate services include nonhospital residential services, partial hospitalization services, and intensive outpatient services such as case management and psychosocial rehabilitation. Psychosocial rehabilitation includes pharmacologic treatment, social skills training, and vocational rehabilitation.
Such services are covered by approximately half of employer-sponsored health plans.
Prescriptions. Are they covered? Coverage of prescription medications is also important in providing access to treatment for mental health disorders. And, on a positive note, Prescription medications are nearly always covered by health plans (U.S. Department of Labor, 1996; 1998), but this coverage is sometimes limited by formulary restrictions.
Check with your healthcare provider for the exact details on what applies to you and your family with regard to your specific circumstances.
Individual health insurance coverage can be acquired with some careful researching of many diverse companies that offer health insurance plans and policies and the cost of an individual health insurance plan will differ from one insurance provider to another. Normally these plans are for individuals that are either self-employed or in some cases unemployed. When compared to an insurance plan that covers groups of consumers working for a small business, the coverage for an individual is more costly .
Perhaps the easiest way to be eligible for better health insurance rates and benefits is to instead forget about signing up for an individual health insurance plan and instead focus on finding a group health insurance plan that they can become a part of with other self employed people or by finding a job that offers such a plan as part of its benefits package.
Still trying to decide between group health insurance and an individual health insurance plan is a decision that can only be made by someone facing that situation. It poaches down to contrasting the two health insurance coverage plans in order to see what really the differences, similarities, advantages and disadvantages are between the two. Only then can a consumer can make the right choice and receive the perceived health insurance coverage they need and deserve.
Individual health plans come in two categories:
Managed care plans
Indemnity plans.
Comparatively Managed Care Health Plans are cheaper than indemnity plans. A managed care health plan is a good option if you want to lessen the cost of an individual health policy. Choice is something that you will need to give up if you decide to buy this plan.
Indemnity Plans are traditional health plans and are definitely more expensive than managed care health plans. The positive aspect here is that you can keep hold of the choice of choosing your health provider. The plan is best for the people who becomes frequently ill and depend only on their trusted doctor or hospital for their treatment.
Once you have decided upon the plan, compare a few individual policies to review their coverage. The best way to do this is to get online quotes and visiting state health department laws. Check for the coverage options and the benefits they provide. In case your friends too have bought individual health coverage, discuss with them their satisfaction level and the drawbacks, if any.