PHP Medicare

PHP Medicare is a non-profit health maintenance organization (hmo). PHP Medicare uses a primary care concept for delivering health care in a health delivery network (hdn) structure. It arranges for the provision of comprehensive outpatient and inpatient medical and surgical services to members on the basis of a fixed prepaid sum without regard to the frequency or extent of services furnished to any particular member. PHP Medicare's commitment is to develop and deliver quality managed care products at a reasonable cost for its members. PHP Medicare is wholly owned by PHP. PHP is primarily a commercial hmo. Along with PHP Medicare, PHP operates PHP insurance company (phpic), a commercial insurance company and PHP service company, a third party administrator. All staffing functions and reporting are accomplished through the use of the same staff as PHP. Unless specifically noted, all references to PHP apply to PHP, phpic, and phpma. Phps service area includes the Michigan counties of ingham, eaton, clinton, shiawassee, montcalm, gratiot, ionia, jackson, hillsdale and portions of isabella, saginaw, washtenaw, and lenawee. PHP ic offers products across Michigan. As of december 31, 2022, there were approximately 28,600 enrollees in phps commercial hmo, 24,800 in tpa, 2,900 in phpic, and 7,500 enrollees in phpma. The PHP network is approximately 3,068 primary care physicians, 5,503 specialty care physicians, 3,906 allied health professionals, 3,482 behavioral health providers and 746 organizational providers that include 60 hospitals. PHP contracts with various hdns who provide healthcare services to members. Phps commitment is to develop and deliver quality managed care products at reasonable costs for its members. Phps success in managing health care is due in part to the extensive network of participating providers in the hdn network. The hmo/hdn contractual arrangements allow PHP to arrange for healthcare to patients covered by the state of michigans medicaid benefit plan. This arrangement allows the members to access a wide variety of independent providers within each hdn including physicians, hospitals, pharmacies, skilled nursing facilities, and allied health professionals. PHP members may also receive care for services from a nonparticipating provider if such referral is recommended by an hdn participating physician and the service required for treatment, as determined by hdn, is not available within the hdns network. PHP offers a variety of healthcare programs, or products to groups and individuals. PHP offers choices that provide coverage within the network of contracted hdn providers, limited coverage outside of the PHP network, various levels of deductibles, co-payments, and coverage limits, all of which are designed to be responsive to customer needs. PHP measures the quality of care provided to its enrollees through annual review of indicators such as: -disease management program participation and outcomes. -quality of care concerns. -hedis measures the health plan effectiveness data and information set (hedis) is a group of nationally recognized measures of health plans performance in a variety of clinical and non-clinical areas. PHP uses the effectiveness of care measures to determine progress and improvement in areas such as: - diabetes, - asthma, - depression and follow-up after mental health admissions, - breast and cervical cancer screening, - use of beta-blockers after heart attacks, - child and adolescent immunizations, - cholesterol management, - controlling high blood pressure, - smoking cessation, - prenatal and postpartum care, and - treatment of childhood respiratory infections. PHP measures the quality of service provided to its enrollees by the review of performance measures related to: - access and availability of providers, - enrollee complaints and appeals, - customer service telephone access performance, and - member assessment: the consumer assessment of healthcare providers and systems (cahps) survey gives a general indication of how well the organization meets members expectations. The PHP qi program is ultimately accountable to the board of directors. In 2020 PHP received full accreditation status from urac for both health plan accreditation and health plan accreditation with health insurance marketplace. Urac accreditation signifies an issuer has undergone and passed a rigorous and independent review of its operation, including the quality of care and level of service provided to enrollees. Accreditation health plan standards incorporate market trends and address major policy issues while aligning with core requirements found in the affordable care act. PHP has been accredited by urac under the health plan standards since 2012. The current accreditation is effective through july 1, 2024 at which time reaccreditation will occur.