Requirements of HMO Act of 1973

[MortalityMan]

I've seen a lot of lists about the benefits/advantages of being deemed an HMO, and the requirements to be considered a non-taxable HMO, but i've never seen anything about requirements for a regular, old-fashion HMO. has anybody else?

[Julietn528]

I think the State Regulation section of the chapter sort of addresses the benefits of an HMO when they are talking about the PPA because there is all that grey area when you have a PPA that is clarified when you are using an HMO.

Also, isn't there a card about HMO's being subject to any willing provider laws, etc. It is like 14 points; I can't remember which section it is from. I'm at work so I don't have all my notecards with me.

[Lar Jep]

Yeah go to chapter 69 in the managed care piece of work. Pretty much the entire chapter is dedicated to the state regulation of HMOs. There is actually quite a bit to know.

[MortalityMan]

oh right - i threw those cards to the side, because a lot of the regulation was the same for PPA's (except the corporate practice of medicine).

I guess I considered regulation seperate from the definition of HMO according to the act, but i guess that's pretty straight forward (provides care, has networks, etc...)

Speaking of, anybody want to compare and contrast HMO's and PPA's? These are the differences I can come up with:

1. PPA's cannot have the 'corporate practice of medicine'
2. PPA's are run/owned by physicians.
3. HMO's have the network thing going on (though PPA's might as well?)....

[Guy Smiley]

oh right - i threw those cards to the side, because a lot of the regulation was the same for PPA's (except the corporate practice of medicine).

I guess I considered regulation seperate from the definition of HMO according to the act, but i guess that's pretty straight forward (provides care, has networks, etc...)

Speaking of, anybody want to compare and contrast HMO's and PPA's? These are the differences I can come up with:

1. PPA's cannot have the 'corporate practice of medicine'
2. PPA's are run/owned by physicians.
3. HMO's have the network thing going on (though PPA's might as well?)....

I don't think those are accurate differences.

Regarding "corporate practice of medicine", this is a common law prohibition. That is, company's could not make medical decisions. However, HMO laws have a specific exemption so that this does not apply to them. For PPAs, it is ambiguous--that is, the prohibition against corporate practice of medicine could be used against them, but isn't.

Both HMOs and PPA can be run/owned by physicians, and both of them can be not run/owed by physicians.

PPA are a network (though they may include utilization review and such as well). The thing with the HMO is that it sells directly to customers (ERs, individuals, CMS)--possibly via a disribution channel--while PPAs usually contract with an insurer or HMO (though PPAs can also contract directly with customers in some cases).

[Julietn528]

The other thing is with a PPA since it is not technically considered an HMO, it is not subject to the same regulations. For example, HMO's are subject to various quality regulations. The reason being that participants an HMO are required to go to a certain doctor, so if they have to go to certain doctors, the regulators have to make sure that the Doctors are up to snuff and they have to pass various quality regulations.

The issue with PPA is that they aren't subject to these quality regulations, so than when they only allow you to go to certain plans, there are complications like the any willing provider law, etc.