Managed Care Health Insurance Plan

Continuing with our discussion on managed care options, apart from the first point Health Maintenance Organizations (HMO) we have the following plans.

2. Preferred Provider Organizations (PPO)

This plan involves levying of charges on a fee-for-service basis. The health insurer pays the participating doctors, hospitals and health care providers on a negotiated, discounted fee schedule. When you choose the in-network healthcare services, the costs are lower but you have the option of going out-of-network, if you desire.

In case, if you wish to select a physician out of the network, you are generally required to pay the difference between what the provider charges and what the plan pays.

3. Point of service plans

Popularly called as POS, these plans have similarity to the indemnity-type option. The primary care doctors selected by the individual generally make referrals to other physicians within the plan.

If the primary care doctor makes a referral out of the plan, the POS plan pays almost all or most of the medical bill. However, if you select an external medical expert yourself (apart from the list prescribed by the health insurance provider), you will be required to bear the cost medical care arising out of such a situation.

C. Health Insurance sponsored by state governments

Apart from the dozens of private players in the health insurance arena, government too has its own schemes to take care of the health of its citizens.

1. Medicaid

It is a federal or state public assistance program created in the year 1965. It is a health insurance plan exclusively created to cater to the needs of poor people who are unable to meet the cost of health insurance provided by private players. It is administered by the concerned state governments. All states have this plan under its ambit but they differ on eligibility levels and coverage benefits.

2. Medicare

It is a federal government program meant for people who are 65 and above in age, or for those who suffer from certain disabilities and this plan has built in option to pay a part of the cost involved in hospitalization, surgery, doctors’ bills, home health care apart from skilled nursing care.

3. State Children’s Health Insurance Program (SCHIP)

Known by different names in different states, this SCHIP is administered at the state level and intended to provide health insurance care to low income or poor children whose parents do not qualify for Medicaid.

4. Military Health Care

The military has its own plans to cater to the needs of the personnel in the uniformed services. There are different plans like Civilian Health and Medical Program of the Uniformed Services (TRICARE / CHAMPUS) and Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). The Department of Veterans Affairs (VA) has its own health insurance plans.

5. Each state has specific plans, known by different names for the welfare of its low-income uninsured individuals.

6. Indian Health Service (IHS)

This plan is offered by the Department of Health and Human Services offering medical assistance to eligible American Indians at IHS facilities. In addition, the IHS helps pay the cost of selected health care services provided at non-IHS facilities.