Florida HMO Plans (Health Maintenance Organziation)

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Florida HMO Plans

Congratulations on visiting the Florida HMO page, a place where not many people will venture. Although this is not a good idea, as learning about HMOs in Florida helped me save a man’s life. That’s right, I saved a man’s life with Vista Health Plan and I will never share the details with anyone except the few privileged that get to buy me a drink and then seduce the information out of me, and unless you’re my wife you don’t have a good chance.  But the good news is, that Florida HMO’s are probably the most benefit rich plans that are available.  People don’t realize this but HMO’s are all about one thing, and if you guessed preventative care then you’d be right. I dare you to get a complete body scan and colonoscopy with your individual PPO plan.

Alright, now that you’re back, give it a few more months for all the bills to get in. Now how are you going to come up with that $2500?  If you had an HMO you would have only paid $150 or so in defined co-pays.  You can get blood work done everyday of your life and you can get surgery in most outpatient clinics for a co-pay as well.  You still have a deductible just like a PPO, but what the true difference is that the deductible only applies most of the time to inpatient hospitalization.  Check out my article on PPOitis on my blog.  More info and HMO Quote Information after the jump.

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Miami and Florida HMO Health Insurance Companies

So, which HMO’s are available to you in South Florida as an Individual?  Well actually there are several but the bad news is most of them are not very good or their networks are weak.  Vista Health Plan in Florida is the main HMO plan to choose from, while the other one which is Medica (a more recent plan to come out) is also very good.

Actually in Miami, there is a new plan which is darn close to an HMO, except that it is open and covers out of network expenses. The crucial difference between an HMO and PPO is that HMOs cover 0% of your out of network costs, while POSs are an HMO platform, but share in common with HMOs out-of-network coverage.

Now if you live in Miami, you might be thinking what about Preferred Medical Plan, or Total Health Choice and the smaller HMO’s in the area.  Their networks are only 4 pages long with hospitals, which means that you will definitely end up with a ton of bills as when you are admitted to a hospital, god forbid, you will almost always get a new bill because the doctor that sees you or the anesthesiologist will most likely not be on the plan.

But even worse, never forget to check your MOOP (maximum out-of-pocket per year which is your deductible plus your coinsurance maximums or your co-pay maximums) and if you have Preferred or many of the other small Miami HMOs you will most likely not even know that your plan includes you paying for 25% of all hospital and major medical expenses.  That means each year of your policy should you be hospitalized you will end up paying 25% of every bill!

This is a scam and no one should ever buy a plan knowingly or unknowingly where they are responsible for 25% or whatever percent of the yearly costs without a cap.

Now on to the boring stuff:  However, read the HMO history section from Wikipedia as it includes a really important set of facts about the evolution of health insurance in America.

Check out our  Vista Health Insurance section

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Stay away from Total Health unless you only need 4 doctors.  Medica is a newer product with a very strong network for an HMO.

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A health maintenance organization (HMO) is a type of managed care organization (MCO) that provides a form of health care coverage in the United States that is fulfilled through hospitals, doctors, and other providers with which the HMO has a contract. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options. Unlike traditional indemnity insurance, an HMO covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO’s guidelines and restrictions in exchange for a steady stream of customers.

Florida HMO Operations

Most HMOs require members to select a primary care physician (PCP), a doctor who acts as a “gatekeeper” to direct access to medical services. PCPs are usually internists, pediatricians, family doctors, or general practitioners (GPs). Absent a medical emergency, patients need a referral from the PCP in order to see a specialist or other doctor, and the gatekeeper cannot authorize that referral unless the HMO guidelines deem it necessary.

“Open access” HMOs do not use gatekeepers – there is no requirement to obtain a referral before seeing a specialist. The beneficiary cost sharing (e.g., co-payment or coinsurance) may be higher for specialist care, however”Open access” HMOs do not use gatekeepers – there is no requirement to obtain a referral before seeing a specialist. The beneficiary cost sharing (e.g., co-payment or coinsurance) may be higher for specialist care, however. HMOs also manage care through utilization review. That means they monitor doctors to see if they are performing more services for their patients than other doctors, or fewer.

HMOs often provide preventive care for a lower copayment or for free, in order to keep members from developing a preventable condition that would require a great deal of medical services. When HMOs were coming into existence, indemnity plans often did not cover preventive services, such as immunizations, well-baby checkups, mammograms, or physicals. It is this inclusion of services intended to maintain a member’s health that gave the HMO its name. Some services, such as outpatient mental health care, are limited, and more costly forms of care, diagnosis, or treatment may not be covered. Experimental treatments and elective services that are not medically necessary (such as elective plastic surgery) are almost never covered.

Other choices for managing care are case management, in which patients with catastrophic cases are identified, or disease management, in which patients with certain chronic diseases like diabetes, asthma, or some forms of cancer are identified. In either case, the HMO takes a greater level of involvement in the patient’s care, assigning a case manager to the patient or a group of patients to ensure that no two providers provide overlapping care, and to ensure that the patient is receiving appropriate treatment, so that the condition does not worsen beyond what can be helped.

Cost containment

Although businesses pursued the HMO model for its alleged cost containment benefits, some research indicates that private HMO plans don’t achieve any significant cost savings over non-HMO plans. Although out-of-pocket costs are reduced for consumers, controlling for other factors, the plans don’t affect total expenditures and payments by insurers. A possible reason for this failure is that consumers might increase utilization in response to less cost sharing under HMOs.

History of HMO’s

The earliest form of HMOs can be seen in a number of prepaid health plans. In 1910, the Western Clinic in Tacoma, Washington offered lumber mill owners and their employees certain medical services from its providers for a premium of $0.50 per member per month. This is considered by some to be the first example of an HMO. However, Ross-Loos Medical Group, established in 1929, is considered to be the first HMO in the United States; it was headquartered in Los Angeles and initially provided services for Los Angeles Department of Water and Power (DWP) and Los Angeles County employees. Approximately 500 DWP employees enrolled at a cost of $1.50 each per month.

Within a year, the Los Angeles Fire Department signed up, then the Los Angeles Police Department, then the Southern California Telephone Company, (now at&t) and more. By 1951, enrollment stood at 35,000 and included teachers, county and city employees. In 1982 through the merger of the Insurance Company of North America (INA) founded in 1792 and Connecticut General (CG) founded in 1865 came together to become CIGNA. Ross-Loos Medical Group, became now known as CIGNA HealthCare.

Also in 1929 Dr. Michael Shadid created a health plan in Elk City, Oklahoma in which farmers bought shares for $50 to raise the money to build a hospital. The medical community did not like this arrangement and threatened to suspend Shadid’s licence. The Farmer’s Union took control of the hospital and the health plan in 1934. Also in 1929, Baylor Hospital provided approximately 1,500 teachers with prepaid care. This was the origin of Blue Cross. Around 1939, state medical societies created Blue Shield plans to cover physician services, as Blue Cross covered only hospital services. These prepaid plans burgeoned during the Great Depression as a method for providers to ensure constant and steady revenue.

In 1970, the number of HMOs declined to less than 40. Paul Ellwood, often called the “father” of the HMO, began having discussions with what is today the U.S. Department of Health and Human Services that led to the enactment of the Health Maintenance Organization Act of 1973. This act had three main provisions:

  • Grants and loans were provided to plan, start, or expand an HMO
  • Certain state-imposed restrictions on HMOs were removed if the HMOs were federally certified
  • Employers with 25 or more employees were required to offer federally certified HMO options alongside indemnity upon request

This last provision, called the dual choice provision, was the most important, as it gave HMOs access to the critical employer-based market that had often been blocked in the past. The federal government was slow to issue regulations and certify plans until 1977, when HMOs began to grow rapidly. The dual choice provision expired in 1995.

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