Health Plan is an entity that provides, offers or arranges for coverage of
designated health services needed by plan members for a fixed, prepaid
premium. There are four basic models of Health Plans:
- Group Model Health Plan: This type of Health Plan contracts
with doctors organized as a partnership, professional corporation or
other association. The health plan compensates the medical group for
contracted services at a negotiated rate, and that group is
responsible for compensating its physicians and contracting hospitals
for care for their patients.
- IPA Health Plan: The Health Plan contracts with an
association of medical professionals to provide medical services in
return for a negotiated fee. The IPA in turn contracts with physicians
who continue in their existing individual or group practices.
- Network Model Health Plan: A health care model in which the
Health Plan contracts with more than one physician group and may
contract with single and multi-specialty groups. The physician may
share in utilization savings, but may not necessarily provide care
exclusively for Health Plan members.
- Staff Model Health Plan: This health care model employs
physicians to provide health care to its members. All premiums and
other revenues accrue to the Health Plan, which compensates physicians
by salary and incentive programs.
Under the Federal Health Plan Act, an entity must have three
characteristics to call itself an Health Plan:
- an organized system for providing health care or otherwise assuring
health care delivery to a geographic area,
- an agreed upon set of basic and supplemental health maintenance and
treatment services,
- a voluntarily enrolled group of people.
WHAT DOES HEALTH PLAN MEMBERSHIP MEAN?
- Quality Care.
- Preventive Measures.
- Affordability.
This is the Health Plan philosophy. When you become a member of an
Health Plan, you join an exclusive health delivery system that provides
high quality care with more comprehensive benefits, more preventive
services and fewer out-of-pocket expenses -- all at an affordable price.
The first step toward enjoying these benefits is the
selection of a personal physician - a health care manager - who
coordinates your care with large team of health care professionals. An
advantage of Health Plan membership is that members have the choice of a
variety of personal physicians who have met the exceptionally high
standards of professional training and competence.
Health Plans encourage their members to visit their personal physician
as frequently as they deem necessary. A working relationship with your
physician is important - to you and your doctor. The more steadily he/she
visits with you, the more likely it is that small problems will be
detected and treated early, avoiding the major problems down the road.
These steady visits comprise what we call preventive care. They include
diagnostic tests, such as mammograms, pap smears, diabetes detection, and
hypertension testing. Health Plans believe in preventive care.
Your membership card is a promise to secure comprehensive, coordinated
care while maintaining costs. Health Plans are solving the kinds of
problems that government has attempted to address in its many reform
packages. Members have reported in survey after survey, that they like the
care they receive. The surveys indicate that members believe that the care
they receive is as good - or better - than old fashioned, traditional
medical care. These members are among the nearly 3 million Floridians
covered by Health Plans today.
HOW DO YOU KNOW IF YOUR HEALTH PLAN IS GOOD?
Quality can and should be measured in different ways. Quality can
signify a clinical aspect - such as the rate of immunization or the use of
prenatal care. On the other hand, it can also address administrative
issues such as how a member is treated on the phone and in person by
Health Plan staff.
Health Plans carry out a number of different quality assurance
exercises. Plans document their performance in a range of quality areas.
There is an assumption that since many Health Plan providers are prepaid
for services, the interest in treating patients would be low. To prevent
such abuse, Health Plans monitor its doctors to be sure that preventive
care and referral services are being used according to the best medical
practice and regulatory standards.
Health Plans are required to sustain an additional level of quality
assurance by federal regulation and state law. These extra measures are
not provided to those in traditional insurance, because those insurers are
not required by law to monitor the quality of care provided by your
doctor. Without a close relationship with doctors, a traditional insurance
plan cannot monitor the quality of care the way Health Plans can.
In our state, the Florida Department of Insurance, in conjunction with
the Agency for Health Care Administration, not only screen Health Plans
for quality of care, but for the financial stability overall. Only state
licensed Health Plans have this type of approval stamp. Additionally, the
Department of Insurance has the power to cap the amount of money any
Health Plan may charge as premium to their members. Health Plans are not
like any other type of business. Contrary to the beliefs of many, Health
Plans may not impose a rate increase on their members without prior
approval from the state government.
Health Plan members have an advantage over those enrolled in
traditional insurance plans.
- 80% of all doctors in Health Plans are currently board certified.
- In traditional "fee for service" plans, this number is
much lower - 60%.
Board certified doctors have been screened and passed a high level of
expectation by their peers and the medical community.
In addition, Health Plans employ full time utilization review
departments and full time medical directors that the Health Plan employs
to assure that you are receiving the most appropriate level of care. Major
medical decisions are reviewed by the Health Plan's medical director or
utilization review nurse, who is trained in recognizing acceptable
standards of medical practice. |
Florida Compare Care
Florida Medicare Managed Care Plans
AmeriChoice/United Health Plan
America's Health Choice
Avmed Health Plan
Blue Cross Blue Shield of Florida --
Health Options
Citrus Health Plan
Health First Health Plan
Humana
Neighborhood Health Partnerships
Quality Health Plan
WellCare/Staywell
Florida Medicaid Managed Care Plans
AmeriChoice/United Health Plan
America's Health Choice
Amerigroup
Citrus Health Plan
Health First Health Plans
Humana
JMH Health Plan
Preferred Medical Plan
Total Health Choice
WellCare/Staywell
Florida Medicaid Financial & Enrollment Reports
Florida
Medicaid Reports
Florida Hospital Data
Florida Hospital Services Guide
Emergency Room Report
Top 30 DRGs
Operating Margin
Chart ($)
Operating Margin
List ($)
Operating Margin
List (%)
Operating Margin Comparing For-Profit and Not-for-Profit ($)
Operating Margin Comparing For-Profit and Not-for-Profit (%)
Total Margin Chart ($)
Total Margin List (%)
Number of Hospitals Making and Losing $
Total Margin of For-Profit and Not-for-Profit Hospitals ($)
Total Margin of For-Profit and Not-for-Profit Hospitals (%)
Health-Related
Resources
The links provided here are a
sampling of the tremendous number of health related sites
accessible online.
Agency for Health Care Policy and Research
http://www.ahcpr.gov/
The AHCPR is the lead agency charged with supporting
research designed to improve the quality of health care,
reduce its cost, and broaden access to essential services.
American 's
Health Insurance Plans
http://www.ahip.org
Bureau of Managed Health Care
http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/index.shtml
The Bureau of Managed Health Care plays an important role
in AHCA's mission to champion accessible, affordable, quality
health care for all Floridians through the oversight and
monitoring of a variety of programs
Centers for Disease Control and Prevention
http://www.cdc.gov/
The CDC's mission is to promote health and quality of life
by preventing and
controlling disease, injury, and disability.
The Web site provides a search engine to enable the visitor to
locate information throughout the site.
Health Care Financing Administration
http://www.cms.hhs.gov/
CMS administers the Medicare and Medicaid programs, which
provide health care coverage to about one in every five
Americans. CMS's regulations are available on-line through
the government printing office Web site, which is linked to
CMS's site.
The Florida Senate
http://www.flsenate.gov/
FLSenate.gov provides an overview of the members and
official activities of the Florida Senate including proposed
legislation, calendars, journals, reports and session
summaries.
The Florida House of Representatives
http://www.myfloridahouse.gov/
The House of Representatives website provides an overview
of the members and official activities of the Florida House of
Representatives including proposed legislation, calendars,
journals, reports and session summaries.
Joint Commission on Accreditation of Healthcare
Organizations
http://www.jcaho.org/
JCAHO evaluates and accredits more than 15,000 health care
organizations in the United States, including hospitals,
health care networks and health care organizations that
provide home care, long term care, behavioral health care,
laboratory, and ambulatory care services.
MyFlorida.com
http://www.myflorida.com/b_eog/owa/b_eog_www.html.main_page
National Committee for Quality Assurance
http://www.ncqa.org
The National Committee for Quality Assurance is dedicated
to improving the
quality of healthcare. NCQA is active in
quality oversight and improvement initiatives at all levels of
the heath care system, from evaluating entire systems of care
to recognizing individual providers that demonstrate
excellence.
Office of Insurance Regulation
http://www.floir.com/
The Office of Insurance Regulation has primary
responsibility for regulation,
compliance and enforcement of
statutes related to the business of insurance
and the
monitoring of industry markets.
U.S. Department of Health and Human Services
http://www.os.dhhs.gov:80/
DHHS administers a wide variety of programs including
Medicare and Medicaid and nearly all of the federal welfare
and children's programs.
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