i need help answering only 4 questions the rest i have done it.
Health
Insurance Matrix
As you learn about health care
delivery in the United States, it is necessary to understand the various models of
health insurance to develop
important foundational knowledge as you progress through the course and for your role as a future health care
worker. The following matrix is designed to help you
develop that knowledge and assist you in understanding how health care is
financed and how health insurance influences patients and providers. Fill in the
following matrix. Each box must contain responses between 50 and 100 words and use complete sentences.
Model
Describe the model
How is the care paid or financed when
this model is used?
What is the structure behind this model?
Is it a gatekeeper, open-access, or combination of both?
What are the benefits for providers in
using this model?
What are the challenges for providers in
using this model?
Health Maintenance Organization (HMO)
.
A
type of health insurance plan that usually limits coverage to care from
doctors who work for or contract with the HMO. It generally won’t cover
out-of-network care except in an emergency. An HMO may require you to live or
work in its service area to be eligible for coverage. HMOs often provide
integrated care and focus on prevention and wellness.
Health
maintenance organizations represent “pre-paid” or “capitated” insurance plans
in which individuals or their employers pay a fixed monthly fee for services
instead of a separate charge for each visit or service. The monthly fees
remain the same, regardless of types or levels of services provided. Services
are provided by physicians who are employed by, or under contract with, the
HMO.
You’ll select
a Primary Care Physician who will be the first point of contact for your
healthcare. You are encouraged to build a strong relationship with your PCP
because they will connect you to specialists or other health care providers.
Your PCP will be able to see the total picture of your overall health.
With an HMO
plan, your out-of-pocket medical costs and monthly premiums will generally be
lower than with other types of plans. If you are someone who doesn’t see a
lot of specialists or would like having your care coordinated through a PCP,
then you might save more money with an HMO plan.
Tight controls can make it more difficult
to get specialized care
As an HMO member, you must choose a
primary care physician (PCP). Your PCP provides your general medical care and
must be consulted before you seek care from another physician or specialist.
This screening process helps to reduce costs both for the HMO and for HMO
members, but it can also lead to complications if your PCP doesn’t provide
the referral you need
Preferred Provider Model
. 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
Rather than
prepaying for medical care, PPO members pay for services as they are
rendered. The PPO sponsor (employer or insurance company) generally
reimburses the member for the cost of the treatment, less any co-payment
percentage. In some cases, the physician may submit the bill directly to the
insurance company for payment. The insurer then pays the covered amount
directly to the healthcare provider, and the member pays his or her
co-payment amount. The price for each type of service is negotiated in
advance by the healthcare providers and the PPO sponsor(s).
Free choice of healthcare
provider
PPO members are not
required to seek care from PPO physicians. However, there is generally strong
financial incentive to do so. For example, members may receive 90%
reimbursement for care obtained from network physicians but only 60% for
non-network treatment. In order to avoid paying an additional 30% out of
their own pockets, most PPO members choose to receive their healthcare within
the PPO network.
Out-of-pocket costs
generally limited
Healthcare costs paid out
of your own pocket (e.g., deductibles and co-payments) are limited.
Typically, out-of-pocket costs for network care are limited to $1,200 for
individuals and $2,100 for families. Out-of-pocket costs for non-network
treatment are typically capped at $2,000 for individuals and $3,500 for
families. And they have a free choice of healthcare provider.
More paperwork and
expenses than HMOs
As a PPO member, you may
have to fill out paperwork in order to be reimbursed for your medical treatment.
Additionally, most PPOs have larger co-payment amounts than HMOs, and you may
be required to meet a deductible. Less coverage for treatment provided by
non-PPO physicians
As mentioned previously,
there is a strong financial incentive to use PPO network physicians.
Point-of-Service Model
A Point of Service (POS)
plan is a type of managed healthcare system that combines characteristics of
the HMO and the PPO. Like an HMO, you pay no deductible and usually only a
minimal co-payment when you use a healthcare provider within your network.
You also must choose a primary care physician who is responsible for all
referrals within the POS network. If you choose to go outside the network for
healthcare, POS coverage functions more like a PPO.
No “gatekeeper”
for non-network care
If you choose to go
outside the POS network for treatment, you are free to see any doctor or
specialist you choose without first consulting your primary care physician
(PCP). Of course, you will pay substantially more out-of-pocket charges for
non-network care.
POS coverage allows you to
maximize your freedom of choice. Like a PPO, you can mix the types of care
you receive. There is no minimal co-payment. Also when you choose to use
network providers, there is generally no deductible. As well as no healthcare
cost paid out of your own pocket
Substantial co-payment for
non-network care
As in a PPO, there is
generally strong financial incentive to use POS network physicians. For
example, your co-payment may be only $10 for care obtained from network
physicians, but you could be responsible for up to 40% of the cost of
treatment provided by non-network doctors. Thus, if your longtime family
doctor is outside of the POS network, you may choose to continue seeing her,
but it will cost you more.
Provider Sponsored Organization
A Provider-Sponsored
Organization (PSO) is a type of managed care plan that is operated by a group
of doctors and hospitals that form a network of providers within which you
must stay to receive coverage for your care. People with Medicare can choose
to get their Medicare benefits through a PSO.
PSO receives a fixed
monthly payment to provide care for Medicare beneficiaries. PSOs may be
developed as for-profit or not-for-profit entities of which at least 51
percent must be owned and governed by health care providers (physicians,
hospitals or allied health professionals). PSOs may be organized as either
public or private entities
The gatekeeper would be
Medicare in the United States can be defined as ‘ A group of doctors, hospitals,
and other health care providers that agree to give health care to Medicare
beneficiaries for a set amount of money from Medicare every month. This type
of managed care plan is run by the doctors and providers themselves, and not
by an insurance company
High Deductible Health Plans and Savings Options
A health savings account
(HSA) is a tax-advantaged medical savings account available to taxpayers in
the United States who are enrolled in a high-deductible health plan (HDHP).
The funds contributed to an account are not subject to federal income tax at
the time of deposit.
You have the freedom to
see any health care provider, including specialists, without a referral,
although you will save money if you see in-network providers. This is
especially important since instead of a copay, you will be paying the full
cost of a doctor’s visit or service until you satisfy your deductible
Others can contribute to
your HSA. Contributions can come from various sources, including you, your
employer, a relative and anyone else who wants to add to your HSA. High
deductible plans also allow you to meet health plan stipulations that your
community may have. By having yourself and your family covered with health
insurance, you can be in compliance with specific laws that require insurance
coverage.
You have high deductible
requirement. Even though you are paying less in premiums each month, it can
be difficult – even with money in an HSA – to come up with the cash to meet a
high deductible.
You have unexpected
healthcare costs. Your healthcare costs could exceed what you had planned
for, and you may not have enough money saved in your HSA to cover expenses.
Cite your sources below. For
additional information on how to properly cite your sources check out the Reference
and Citation Generator resource in the Center for Writing Excellence.
References
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