Managed Care and Accountable Care Organizations

Managed Care and Accountable Care Organizations

Introduction

An individual may buy health insurance by himself or herself or by involving their boss. Upon buying a health insurance, one is enrolled in a certain form of the many available types of Managed Care Plans. The access to health care and the type of services offered by health care to the individual depends on the type of the Managed Care Plan. Some plans cater for the insured individual and their family. Other plans require that the insured individual pays part of the medication fees from their pockets.

Various Types of Managed Care Plans in Our Organization

  • Health Maintenance Organizations

By this type of plan, an individual enjoys overall health maintenance. The person being insured with such an organization is expected to choose a principal care physician whose task will be to manage and coordinate all the health care services received by the individual. For specialized treatment such as X- rays, the principal physician is in charge of giving referrals. If the individual chooses to visit a doctor without being referred by the principal physician, then the cost incurred is not paid by the insurance organization (Bard & Nugent, 2011). 

  • Preferred Provider Organizations

This is a type of health plan when a company has contracts with a number of health institutions which an individual who works for the company can choose from. The person does not require a principal physician to refer them to any of the health institutions. When the individual gets services from the institutions which have a contract with the company, they are only responsible for the annual deductions from their salary and a co-payment for visiting the health institution.

 

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  • Point of Service Plans

This is where both the Health Maintenance Organizations plan and the Preferred Provider Organizations plan are combined. In this network, you choose a principal physician who will be managing and coordinating your health care, while at the same time, the plan allows you to seek services from another health care provider. This is why the plan gets its name as the Point of Service: any time you need to seek medical attention, you can decide what is convenient for you at the time, whether you are seeking medication outside or from your principal physician (Bard & Nugent, 2011). 

Comparison of the Managed Care Plans in Our Organization

In Health Maintenance Organizations, an individual gets to choose their principal physician, while in Preferred Provider Organizations, the company that the individual works for makes contracts with a number of health providing institutions on behalf of its staff members. As for the Point of Service plan, the individual chooses a principal physician, but at the same time, they can seek medical attention from another physician without consulting with the designated principal physician (Pavarini, 2012).

 

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For Health Maintenance Organizations, an individual has to be referred by their principal physician in order to consult a specialist. The only exception is emergency cases. For Preferred Provider Organizations, the individual does not require referrals in order to see a specialist (Bard & Nugent, 2011). As for Health Maintenance Organizations, one has to file an insurance claim to be paid for the treatment, while for Preferred Provider Organizations, one is not required to file such a claim. Notably, if one seeks medication privately from another medical provider, they are expected to pay for the service from their pocket, and then submit an insurance claim for the money to be refunded (Pavarini, 2012).

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