提上来回答什么是PPO, HMO等保险计划

by 也潜水

PPO- preferred provider organization

A PPO (Preferred Provider Organization) is a network of doctors,hospitals and other health care providers that have been contracted byan insurance company or health plan to provide care at a discount. PPOPlans have two benefit schedules -- one for In-Network and another forOut-Of-Network services.

PPO 一般可以去network里面任何专科医生或医疗机构看病,
由保险公司支付承诺的费用,病人自己只要承担少量费用. 但
在network以外的地方看费用比较高. 好处是可以在network
里任意选择医生(大多数的医生都和几个主要的PPO保险签的),
医生在保险范围内会尽量给最好的治疗. 缺点是出了network
的医生自付部分相对高.

HMO- Health Health Maintenance Organization

Each HMO member selects a Primary Care Physician (PCP) from a directoryof participating physicians in the areas of general practice, familypractice, internal medicine or pediatrics. The PCP will coordinate allof the member's health care needs. If the PCP can effectively providecare, he will. If he determines a specialist is needed, he will referthe member to a Participating Specialist in the HMO network.

HMO最大的好处是自付费用非常低,由一位主要医生负责
一般病情,主要医生觉得他不能处理时推荐给专科医生.
缺点是你不能自己选专科医生,如果遇到自私或不负责的
主要医生,你可能得不到最有经验的医生的治疗. 另外如
果医院本身就是保险公司(比如象Kaiser这样的医院),
尽量要节省成本,有时会有利益冲突.

POS- Point of Service
这是HMO和PPO混合的一种保险.
小毛病可以和HMO一样找主要医生看或听从他选择的专科
医生,费用很低. 如果不满意主要医生的意见也可以找别
的医生或不是他推荐的专科医生看,但这部分自付费用比
较高.

Indemnity Plan
没有network只分,可以找任何医生看. 缺点是自付费用
比较高.