Question

Part 3.

Discuss the four (4) managed health care organizations.

Discuss the provisions for EMTALA and ERISA.

Answer 1

In general, there are various forms of managed care organizations. These programs are network-based, which means that care for Medicaid enrollees is provided within a specific region of the provider's network. Therefore, they have differences in restriction levels, with some programs being very restrictive while others being less restrictive with respect to the specific network. Currently, there are three main types of managed care organizations: Health Maintenance Organizations (HMOs), Preferred Caregiver Organizations (PPOs), and Point of Service (POS) plans.

Preferred Supplier Organizations (PPO)

Preferred provider organizations are health care entities in which individuals enrolled in a specific network receive health care services purchased under a contract between the health insurance company and the employer's health care benefits plan. Within this network, the PPO develops the payment levels and reimbursement procedures that are accepted by the participating healthcare providers. Unlike HMOs, PPOs allow their members to use non-PPO providers. However, this attracts higher levels of discounts for members. Despite differences observed in PPOs, especially those that operate only on a specialist basis, they all share common characteristics regarding provider network, usage management, consumer choice, and negotiated payment rates. In most cases, PPOs create contractual relationships with doctors and hospitals, depending directly or indirectly on service providers ’scope, community reputation, and profitability.

Point of Service (POS) plans

In practice, POS uses other programs, notably HMO health plans. It links compensation coverage to these health plans, particularly through coverage of health services provided to private plan members outside their networks. One of the main advantages of the point of sale is that the plan does not allow members to choose their preferred system until the point of service. This type of OLS is gaining popularity due to its flexibility.

Health maintenance organizations (HMOs)

Health maintenance organizations refer to organized health systems. These health systems provide a wide range of health services to specific populations enrolled in Medicaid programs. In addition, they finance sponsorship for registrants. As such, the HMO operates as a combination of a responsible healthcare delivery management system and a health insurance company. In principle, these organizations coordinate or provide health services to those enrolled in the program, mainly through affiliated healthcare providers. These healthcare providers are then compensated through various platforms, unlike the traditional health insurance system where insurance companies compensate the registrars for their health costs. On the other hand, the HMOs guarantee the adequacy and quality of the health services they provide to members within their networks.