Instruct: Given a question, retrieve documents that can help answer the question.
Query: How are PPOs different from HMOs?
A preferred provider organization[1] is a subscription-based medical care arrangement. A membership allows a substantial discount below the regularly charged rates of the designated professionals partnered with the organization. Preferred provider organizations themselves earn money by charging an access fee to the insurance company for the use of their network (unlike the usual insurance with premiums and corresponding payments paid either in full or partially by the insurance provider to the medical doctor). They negotiate with providers to set fee schedules, and handle disputes between insurers and providers. PPOs can also contract with one another to strengthen their position in certain geographic areas without forming new relationships directly with providers. This will be mutually beneficial in theory, as be billed at a reduced rate when its insureds utilize the services of the "preferred" provider and the provider will see an increase in its business as almost all insureds in the organization will use only providers who are members. PPOs have gained popularity because, although they tend to have slightly higher premiums than HMOs and other more restrictive plans, they offer patients more flexibility overall.[2]
In terms of using such a plan, unlike an HMO plan, which has a copayment cost share feature (a nominal payment generally paid at the time of service), a PPO generally does not have a copayment but offers a deductible and a coinsurance feature. The deductible must be paid in full before any benefits are provided. After the deductible is met, the coinsurance benefits apply. If the PPO plan is an 80% coinsurance plan with a $1,000 deductible, the patient pays 100% of the allowed provider fee up to $1,000. The insurer will pay 80% of the other fees, and the patient will pay the remaining 20%. Charges above the allowed amount are not payable by the patient or insurer but written off as a discount by the physician.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 renamed +Choice plans to "Medicare Advantage" plans. Other managed Medicare plans include COST plans, dual-eligible (Medicare/Medicaid) plans and PACE plans (which try to keep seniors that need non-medical custodial care in their homes). However 97% of the beneficiaries in Part C are in one of the roughly one dozen types of Medicare Advantage plans (HMO, EGWP, SNP, regional PPO, etc.), primarily in classic vanilla HMOs. The terms +Choice and Medicare Advantage were/are government artefacts and often are not visible to the beneficiary of the health plan.
Harvard Pilgrim is among America’s highest-rated health plans according to an annual ranking by the National Committee for Quality Assurance (NCQA). Harvard Pilgrim Health Care is currently rated 5 out of 5 for its private HMO/POS and PPO plans and Harvard Pilgrim Health Care of New England is currently rated 4.5 out of 5 for its private HMO/POS plans in NCQA’s Private Health Insurance Plan Ratings 2015-16.
Apart from the statutory definition of HMOs requiring a mandatory licence, Local Authorities have the power to introduce approved licensing schemes which include smaller HMOs as licensable. Typically these are for 3 or more tenants forming more than 1 household.
The Council Tax (Liability for Owners) Regulations 1992 provide a different definition of HMO that is used solely for determining Council Tax liability.
Along with the four PPO plan options administered by Blue Cross Blue Shield of Texas, a part of Health Care Service Corporation, and Medco, there are three health maintenance organization (HMO) options offered under TRS-ActiveCare for the 2011-2012 plan year: FirstCare Health Plans, Scott & White Health Plan, and Valley Baptist Health Plans. These HMO options will provide additional plan choices to the employees of participating entities in areas served by these HMOs. These employees will be able to select TRS-ActiveCare coverage under one of the PPO plans or through the authorized HMO serving their part of the state.
Golden Rule became a UnitedHealthcare company in 2003. UnitedHealthcare’s individual line of business, which includes Golden Rule, PacifiCare, American Medical Security (AMS), MAMSI, Oxford Health Plans and UnitedHealthcare administered by Golden Rule, currently offers PPO health insurance and HMO products to individuals and families in 40 states and the District of Columbia.
Defying many analysts' expectations, PPOs have gained market share at the expense of HMOs over the past decade.
Fallon Health's product portfolio includes HMO, POS and PPO plans as well as Medicaid and Medicare Advantage plans. In addition, Fallon Health offers a Program of All-inclusive Care for the Elderly, called Summit ElderCare®, and a Medicare Advantage Special Needs Plan/Senior Care Options program, called NaviCare.
PPOS is a conditional probability conditioned on randomly observed data and hence is a random variable itself. Currently common practice of PPOS uses only its point estimate in applications. This can be misleading. For a variable, the amount of uncertainty is an important part of the story. To address this issue, Tang introduced PPOS credible interval to quantify the amount of its uncertainty. Tang advocates to use both PPOS point estimate and credible interval in applications such as decision making and clinical trial designs.
Another common issue is the mixed use of posterior probability of success and PPOS. As described in the previous section, the 2 statistics are measured in 2 different metrics, comparing them is like comparing apples and oranges.
Just as the more loosely managed PPOs have edged out HMOs, HMOs themselves have also evolved towards less tightly managed models. The first HMOs in the U.S., such as Kaiser Permanente in Oakland, California, and the Health Insurance Plan (HIP) in New York, were "staff-model" HMOs, which owned their own health care facilities and employed the doctors and other health care professionals who staffed them. The name health maintenance organization stems from the idea that the HMO would make it its job to maintain the enrollee's health, rather than merely to treat illnesses. In accordance with this mission, managed care organizations typically cover preventive health care. Within the tightly integrated staff-model HMO, the HMO can develop and disseminate guidelines on cost-effective care, while the enrollee's primary care doctor can act as patient advocate and care coordinator, helping the patient negotiate the complex health care system. Despite a substantial body of research demonstrating that many staff-model HMOs deliver high-quality and cost-effective care, they have steadily lost market share. They have been replaced by more loosely managed networks of providers with whom health plans have negotiated discounted fees. It is common today for a physician or hospital to have contracts with a dozen or more health plans, each with different referral networks, contracts with different diagnostic facilities, and different practice guidelines.
Coverage under Dr. Dynasaur is comprehensive prenatal care, routine check-ups, immunizations, hospital care (both inpatient and outpatient), prescriptions, x-ray and lab tests, limited dental and vision services and other medical services. Most Dr. Dynasaur beneficiaries receive services through an HMO or PPO. No co-payments apply for any of these services.
In 1970 Ellwood was invited to consult with President Nixon's staff to reshape national health policy, where he advanced the idea of giving consumers a choice among health plans that would compete on price and quality. He coined the term Health Maintenance Organization, or HMO, to describe groups of physicians who were pre-paid on a per-patient basis (capitation) instead of a fee-for-service arrangement. While the term "HMO" was Ellwood’s, this institutional model already existed in the form of the non-profit Kaiser health plan in California. Ellwood argued that creating a system of many competing HMOs would give health providers an incentive to keep patients well while driving down health care costs. Doctors would promote preventive medicine and would be less inclined to order costly procedures that had not been proven to improve health outcomes. Ellwood’s work with the Nixon administration culminated in the passage of the Health Maintenance Organization Act of 1973. The result was a dramatic change to the landscape of health care in the United States: the proliferation of HMOs, Preferred Provider Organizations (PPOs), and Independent Provider Associations (IPAs) alongside traditional fee-for-service arrangements.
Over time, the operations of many Blue Cross and Blue Shield operations have become more similar to those of commercial health insurance companies. However, some Blue Cross and Blue Shield plans continue to serve as insurers of last resort. Similarly, the benefits offered by Blues plans, commercial insurers, and HMOs are converging in many respects because of market pressures. One example is the convergence of preferred provider organization (PPO) plans offered by Blues and commercial insurers and the point of service plans offered by HMOs. Historically, commercial insurers, Blue Cross and Blue Shield plans, and HMOs might be subject to different regulatory oversight in a state (e.g., the Department of Insurance for insurance companies, versus the Department of Health for HMOs). Today, it is common for commercial insurance companies to have HMOs as subsidiaries, and for HMOs to have insurers as subsidiaries (the state license for an HMO is typically different from that for an insurance company). At one time the distinctions between traditional indemnity insurance, HMOs and PPOs were very clear; today, it can be difficult to distinguish between the products offered by the various types of organization operating in the market.
HMOs often have a negative public image due to their restrictive appearance. HMOs have been the target of lawsuits claiming that the restrictions of the HMO prevented necessary care. Whether an HMO can be held responsible for a physician's negligence partially depends on the HMO's screening process. If an HMO only contracts with providers meeting certain quality criteria and advertises this to its members, a court may be more likely to find that the HMO is responsible, just as hospitals can be liable for negligence in selecting physicians. However, an HMO is often insulated from malpractice lawsuits. The Employee Retirement Income Security Act (ERISA) can be held to preempt negligence claims as well. In this case, the deciding factor is whether the harm results from the plan's administration or the provider's actions. ERISA does not preempt or insulate HMOs from breach of contract or state law claims asserted by an independent, third-party provider of medical services.
The Insurance Commissioner does not oversee the majority of Health Plans and Health Insurance. HMO Health Plans and PPO Plans offered by Anthem Blue Cross and Blue Shield of California are overseen by the California Department of Managed Health Care.
GHI – originally named Group Health Association of New York – was established in 1937 to provide New York’s working families with access to medical services regardless of cost. This new health care model – built around a network of participating providers – was a precursor to today’s preferred provider organization (PPO).
In order to expand its presence in the upstate New York market, GHI established GHI HMO as an incorporated entity in New York State in May 1999. The following month, GHI HMO acquired certain assets of Well Care Management Group, Inc.
Additionally, California has a Help Center that assists Californians when they have problems with their health insurance. The Help Center is run by the Department of Managed Health Care, the government department that oversees and regulates HMOs and some PPOs.
Health Care Settings: these include hospitals (for-profit and public), medical care clinics, home health agencies, HMOs and PPOs. Here, a health educator teaches employees how to be healthy. Patient education positions are far and few between because insurance companies do not cover the costs. [1]
The primary party organization (PPO) was the lowest level in the CPSU hierarchy. PPOs were organized cells consisting of three or more members. A PPO could exist anywhere; for example, in a factory or a student dormitory. They functioned as the party's "eyes and ears" at the lowest level and were used to mobilize support for party policies. All CPSU members had to be a member of a local PPO. The size of a PPO varied from three people to several hundreds, depending upon its setting. In a large enterprise, a PPO usually had several hundred members. In such cases, the PPO was divided into bureaus based upon production-units. Each PPO was led by an executive committee and an executive committee secretary. Each executive committee is responsible for the PPO executive committee and its secretary. In small PPOs, members met periodically to mainly discuss party policies, ideology or practical matters. In such a case, the PPO secretary was responsible for collecting party dues, reporting to higher organs and maintaining the party records. A secretary could be elected democratically through a secret ballot, but that was not often the case; in 1979, only 88 out of the over 400,000 PPOs were elected in this fashion. The remainder were chosen by a higher party organ and ratified by the general meetings of the PPO. The PPO general meeting was responsible for electing delegates to the party conference at either the district- or town-level, depending on where the PPO was located.
UPMC Insurance Services, operating under the umbrella UPMC Health Plan brand, was founded in 1998 and includes various for-profit and non-profit health care financing initiatives. The integrated products of the UPMC Insurance Services Division include UPMC Health Plan (HMO), UPMC Health Network (PPO), Work Partners (workers' compensation and disability for employers), UPMC for Life (Medicare products), UPMC for You (HMO for Medical Assistance beneficiaries), and Community Care Behavioral Health Organization (a non-profit behavioral health PPO for Medical Assistance beneficiaries). These products combine to offer a full range of HMOs, PPOs, and EPOs for group health insurance, Medicare, CHIP, Medical Assistance, behavioral health, employee assistance, and workers' compensation products and services. UPMC also offers consumer-directed health plans like health savings accounts and health reimbursement arrangements. UPMC's provider networks total more than 138 hospitals and more than 16,500 physicians across Pennsylvania and has around three million members making it the largest insurer in Western Pennsylvania. It is also ranked as one of the top commercial health plans in the United States according to "U.S. News & World Report". Also included in the Health Services Division are LifeSolutions, an employee assistance program; EBenefits Solutions, a web-based human resources consulting and benefits administration services; and Askesis Development Group, a software development group for behavioral health care.
In 2007, 87% of Californians had some form of health insurance. Services in California range from private offerings: HMOs, PPOs to public programs: Medi-Cal, Medicare, and Healthy Families (SCHIP).
Original "fee-for-service" Medicare Parts A and B have a standard benefit package that covers medically necessary care as described in the sections above that members can receive from nearly any hospital or doctor in the country (if that doctor or hospital accepts Medicare). Original Medicare beneficiaries who choose to enroll in a Part C Medicare Advantage or other Part C health plan instead give up none of their rights as an Original Medicare beneficiary, receive the same standard benefits—as a minimum—as provided in Original Medicare, and get an annual out of pocket (OOP) upper spending limit not included in Original Medicare. However they must typically use only a select network of providers except in emergencies or for urgent care while travelling, typically restricted to the area surrounding their legal residence (which can vary from tens to over 100 miles depending on county). Most Part C plans are traditional health maintenance organizations (HMOs) that require the patient to have a primary care physician, though others are preferred provider organizations (which typically means the provider restrictions are not as confining as with an HMO). Others are hybrids of HMO and PPO called HMO-POS (for point of service) and a few public Part C health plans are actually fee for service hybrids.
After many years of law practice, Jerry was recruited to become the Senior Vice President and Chief Counsel of PHP Healthcare Corporation, a diversified health care company which operated health clinics for major US Corporations, owned HMOs, and specialized in developing managed health care. PHP was an integrated delivery system which operated networks and health care clinical services in over 30 states. As a shareholder of PHP, Jerry represented over 40 different HMOs and PPOs that participated in the Medicare risk contract program. He was also a key figure in the development of the Oregon Medicaid program that greatly expanded care to children, provided managed care on a wide scale and defended its rationing program.
The terms "open panel" and "closed panel" are sometimes used to describe which health care providers in a community have the opportunity to participate in a plan. In a "closed panel" HMO, the network providers are either HMO employees (staff model) or members of large group practices with which the HMO has a contract. In an "open panel" plan the HMO or PPO contracts with independent practitioners, opening participation in the network to any provider in the community that meets the plan's credential requirements and is willing to accept the terms of the plan's contract.