Spencer Flat
Ch. 16 Case Application
A.) Health Maintenance organization HMO
– this plan covers a range of health benefits including
preventative benefits on payments of a set monthly fee. However, they must use the health care
providers and facilities within the HMO network. Provides for, child wellness visits, shots, etc.
Points of Service POS
– This is a plan offered under HMO plans. It allows members to refer themselves
outside HMO network and still get some coverage.
Preferred Provider Organization PPO
– Doctors, hospitals and other care providers accept lower fees
from the insurer for their services so that they can be a part of the PPO network. Cost sharing is lower
when you go outside the network.
High Deductible Plans
– Are also known as consumer directed plans, the employers and health plans
shift more payment responsibility on the plan members. There are large deductibles that a patient is
liable for before the insurance benefits kick in.
B.) HMO’s have lower cost compared to PPO’s, HMO’s are comparatively less flexible than PPO’s, In
HMO’s you must select a primary physician in their network and PPO’s don’t make you do this, in HMO’s
you need a referral to see a specialist and do not need one in PPO’s, If you see a doctor outside of the
HMO network you will be required to pay the full bill but in PPO’s you will still get some portion of the
bill covered.
C.) Yes, there are group insurance benefits that Megan can consider. This plan will provide health
insurance for employees or a group of people and tends to be less that individual plans which is why she
would consider it.
D.) Since Megan is concerned about the rising health care cost that may arise, she should go for the high
deducible group healthcare plan. Under this plan the payments will only be required after the patient
has incurred cost with respect to the same.
