Managed care plans such as HMOs and PPOs have a network of doctors, hospitals, pharmacies, and other types of medical providers from which the insured individual and their family receive health care services. some managed care plans require the insured individual to receive their health care services from a health care provider in the network. Other managed care plans allow insured individuals to receive medical services outside of the network, but individuals that choose to do so are generally subjected to larger out-of-pocket costs. before choosing a managed care plan to provide for their family’s wellness, it will be important for individuals to determine if a HMO or PPO best meets their family’s needs.
Health Maintenance Organization (HMOs)
Health Maintenance Organization (HMO) managed care plans require individuals to receive most of their health care services from a network provider. while this may appear to be a detriment at first glance, receiving health care services from a network provider can be quite beneficial. Individuals enrolled in HMO plans will select a primary care physician (PCP). the individual’s PCP will be the doctor responsible for coordinating and managing all of the individuals’ health care needs. Depending on the age of the insured and his or her needs the PCP may be a family physician or pediatrician. when choosing a pediatrician for one’s child, parents should consider a Children’s Physicians Medical Group pediatrician.
With an HMO plan, if the insured or a family member needs the services of a specialist, their PCP will provide them with a referral. For example, if a child enrolled with Children’s Physicians Medical Group needs the services of a pediatric specialist their PCP can provide them with the referral they need.
Preferred Provider Organization (PPO)
Preferred Provider Organization (PPO) managed care plans allow insured individuals to use any of the preferred providers in the network for their wellness needs. Insured individuals are not required to select a primary care physician (PCP), and they do not need referrals to visit other health care providers in the network. However, some specialists will only see those individuals that have received a referral from a PCP. For example, if a child is in need of pediatric specialist services they may be required, by the specialist office, to receive a referral from their pediatrician before an appointment can be scheduled.
There are some limitations that may arise with a PPO managed care plan. In some cases, PPO network providers must obtain approval before they refer patients for specific health care services. this is especially true if the medical services or tests the individual requires are expensive. If insured individuals use the services of a health care provider outside of the network the individual will be responsible for paying for the services in full and then submitting a claim form for reimbursement. PPO plans often require the insured individual to pay an annual deductible as well as coinsurance.