Notes

C930549
Join@618

IEX-

PCSE- Partnership of customer service excellent

Manage Care- Health care delivery system that monitors the utilizing and provides quality health care service.
-Quality care at an affordable price.


Tier 1: HMO (Health Maintenance Organization) you can only go to doctors, other health care providers, or hospitals on the plan's list except in an emergency. You may also need to get a referral from your primary care doctor. (Given by the employer) Member is responsible.
-Always has PCP, PPG, No Deductible, (No out of pocket) -member selected
-Ex. Maxicare, Intellicare, 68236 article on ccc
-Only available in California.
Out of pocket of the member is the PCP is out of network. If needed to be refer the PCG must be in network.
OOPM- Out of pocket
Member chooses the Medical Group, Make sure that her PCP is incline with the Medical Group

Tier 2: PPO (Preferred provider group) A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network . You pay more if you use doctors, hospitals, and providers outside of the network.
-Self-refer, can choose any doctor as long as contracted by Health Net, deductible apply, MAA,
-No medical group, the only Doctor is the only one that is contracted with the Health Net.
-Most commonly available in Arizona.
-Mostly deductible apply 68362
Tier 3: OON (Out of Network) -Member's Responsibility.
-Member can see any licensed provider,
-OOPM applies
-Doctor cannot bill higher than MAA
-no co-payment and no co-insurance

Capitations: is a payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.

PPG (Participating Physician Group)- Group of Physicians in a Medical Group
PCP (Primary Care Physician)- One in-charged for the the services of an individual.
MAA (Maximum Allowable Amount) -Covered Partially by the Health Net. Agreed standard amount of state and the health provider. Included on PPO. Remainder of the MAA is members responsibility.

Tier 1 HMO- It is the type of plan that needs to have PCP, PPG and There is No Deductible, Only available in California, if in case the member wanted to have another PCP