FINANCING HEALTH CARE

Direct out of Pocket charge made to the individual who receives health care for treatment received Private Health Insurance involves an insurance contract between private insurance companies and individuals who consider themselves to be at risk of ill health

Public Health Insurance an individual has the opportunity to purchase health insurance from only one insurance company, the government Direct Taxation System derivative of public health insurance where the role of the insurance company is again played solely by the government

HEALTH MAINTENANCE ORGANIZATION : HMO

Health Maintenance Organization. A form of health insurance combining a range of coverages in a group basis. A group of doctors and other medical professionals offer care through the HMO for a flat monthly rate with no deductibles. However, only visits to professionals within the HMO network are covered by the policy. All visits, prescriptions and other care must be cleared by the HMO in order to be covered. A primary physician within the HMO handles referrals.

International Organizations : Aetna CIGNA Kaiser Permanente Humana Health Net Universal American Wellpoint

Types of HMOs
HMOs operate in a variety of forms. Most HMOs today do not fit neatly into one form; they can have multiple divisions, each operating under a different model, or blend two or more models together. Staff Model, physicians are salaried and have offices in HMO buildings. In this case, physicians are direct employees of the HMOs. This model is an example of a closed-panel HMO, meaning that contracted physicians may only see HMO patients. Group Model, the HMO does not employ the physicians directly, but contracts with a multi-specialty physician group practice. Individual physicians are employed by the group practice, rather than by the HMO. The group practice may be established by the HMO and only serve HMO members ("captive group model"). Example : Kaiser Permanente Network Model, an HMO will contract with any combination of groups, IPAs, and individual physicians. Since 1990, most HMOs run by managed care organizations with other lines of business (such as PPO, POS and indemnity) use the network model.

MEMBERSHIP BENEFITS AND PRIVILEGES The following no charge hospitalization (In-Patient) services will apply when MEDICARD physicians prescribe the hospitalization of members in any MEDICARD Hospitals or MEDICARD centers:

No deposit upon admission Room & Board according to type of enrollment Use of operating theater and Recovery Room Services of MEDICard specialist like anaesthesiologists, internists, surgeons, etc. Services and medications for general/spinal anaesthesia or other forms of anaesthesia deemed necessary for a surgical procedure. Fresh whole blood transfusions and intravenous fluids X-ray and Laboratory examinations Administered medicines Dressings, plaster casts, sutures and other items directly related to the medical management of the patient ICU confinements, Chemotherapy, Radiotherapy, and Dialysis are covered subject to maximum limits and pre-existing conditions coverage Modern therapeutic modalities and interventional surgical procedures such as, but not limited to laparoscopic surgery and lithotripsy, are covered up to P20,000 each per years subject to the pre-existing conditions coverage CT Scan, MRI and ultrasound are covered up to P50,000 each per member per year subject to the pre-existing conditions coverage (inclusive of room and board, operating room charges, professional fees and other incidental expenses relative to the procedure):

ADVANTAGES

DISADVANTAGES

Less Paperwork Fewer Expenses Broader Coverage

Limited Choice Affiliation Period

Essentials in Choosing HMO

The HMO Itself :
Contact the Department of Insurance to find out if the HMO is licensed . Contact the Department of Insurance or check the consumer complaint ratios on-line to check the HMO's consumer complaint record. Ask your friends or family if they belong to the HMO, and whether they are happy with the services and care provided to them.

The HMO Plan

Is it affordable? How do the premiums and copayments compare to other HMOs offering similar benefits? Do the benefits match your needs? Are any services you need not covered? How does the plan treat preexisting medical conditions? (For example, even though an HMO can't exclude a preexisting condition, it can require a higher copayment.)

The HMO Health Providers

Are the HMO providers familiar to you? Are they conveniently located? Is there a wide choice of physicians, specialists and hospitals? Are the HMO providers accepting new patients? Is your current doctor or specialist with the HMO? If so, is he or she satisfied with the HMO and planning to continue with the HMO? Is it easy to change Primary Care Physicians?

PPO : Preferred Provider Organization

preferred provider organization (or "PPO", sometimes referred to as a participating provider organization or preferred provider option) is a managed care organization of medical doctors, hospitals, and other health care providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients.

PPO : Preferred Provider Organization.

These organizations also have contractual relationships with insurance companies. However, PPOs are more loosely organized and are not as restrictive as HMOs. If you have a PPO, you can see whatever doctor you like, but if you choose an out-of-network physician, you will have to pay more out-of-pocket. You will not need a referral to see a specialist. PPOs cost more than HMOs, but many people choose them because they are less restrictive. You will have more control over your own healthcare decisions than you would have under an HMO.