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Types of Managed Florida Health Insurance Care Plans

Types Of Managed Care

Health Maintenance Organizations (HMOs)

HMO members pay a monthly fixed dollar amount (similar to an insurance premium), which gives them access to a wide range of health care services. In many cases, members also pay a predetermined amount, or copayment, for each doctor or emergency room visit and for prescription drugs, rather than paying the provider in full and obtaining a portion of the reimbursement later. Recent legislative and regulatory changes have provided HMOs with the opportunity to offer plans with deductibles and coinsurance similar to PPOs (discussed below). HMO members often have little or no paperwork to complete due to the elimination of reimbursement. They must use the HMO's network of providers, which may include the doctors, pharmacies and hospitals under contract with that particular HMO.

You may obtain the free publication Health Maintenance Organizations: A Guide for Consumers by calling the Consumer Helpline toll-free at 1-877-MY-FL-CFO (1-877-693-5236), or by downloading it from the DFS Web site at www.MyFloridaCFO.com.

Exclusive Provider Organizations (EPOs)

In an EPO arrangement, an insurance company contracts with hospitals or specific providers. Insured members must use the contracted hospitals or providers to receive benefits from these plans.

Preferred Provider Organizations (PPOs)

A PPO offers another kind of provider network to meet the health care needs of consumers. A traditional insurance carrier provides the health benefits. An insurer contracts with a group of health care providers to control the cost of providing benefits to consumers. These providers charge lower-than-usual fees because they require prompt payment and serve a greater number of patients. Consumers usually choose who will provide their health services, but pay less in coinsurance with a preferred provider than with a non-preferred provider.

Point-of-Service Plans

These plans may be called by a variety of names and have various features. They combine some aspects of traditional medical expense insurance plans and other aspects of HMOs and PPOs. In a POS plan, insured members may choose, at the point of service, whether to receive care from a physician within the plan's network or to go out of the network for services. The POS plan provides less coverage for health care expenses provided outside the network than for expenses incurred within the network. Also, the POS plan will usually require you to pay deductibles and coinsurance costs for medical care received out of network.

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