SISTEMA DE CONTROL Y PROTECCIONES DE TURBOGENERADORES
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Name: Baraah El-Haik
Health Insurance Matrix HCS/235 Version 4
University of Phoenix Material Health Insurance Matrix
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Origin: When was the model first used?
Health maintenan#e organi(ation )H*O+
,-amle: HM"s first emer#ed in the 1$%&s 'ith (aiser Permanente in )alifornia and the Health Insurance Plan in Ne' *ork! Ho'eer+ they 'ere not adopted 'idely until the 1$,&s+ 'hen health care costs increased and the federal #oernment passed the
What kind of a!ment s!stem is used" su#h Who a!s for as #are? rose#ti$e" retrose#ti$e" or #on#urrent? ,-amle: ,-amle: HM"s often In #roup operate on a policies+ 'here prospectie or health prepaid insurance is payment proided system 'here throu#h the proiders are employer+ the paid a employer pays capitated fee the insurance one flat company a set amount per amount a#reed .eneficiary upon in per month+ adance! /uarter+ or Accordin# to year+ Austin and re#ardless of 4etle 05&156+ the fre/uency employers or /uantity of coered 789 of serices used premium costs 0Barsukie'ic+ for sin#le 2affel+ 3 coera#e and
What is the a##ess stru#ture" su#h as gatekeeer" oen%a##ess" and so forth?
How does the model affe#t atients? &n#lude ros and #ons'
,-amle: HM"s hae the strictest access structure+ called a #atekeeper model+ 'here patients must hae a primary care physician 0P)P6 throu#h 'hom all care is routed! P)Ps decide 'hich dia#nostic tests are needed and control access to specialists throu#h referrals+ decidin# 'hen it is necessary for a patient to seek more expensie
,-amle: ,-amle: HM"s are usually the Adanta#es of HM"s HM"s are least expensie health that a kno'n amount of plans+ offer predicta.le reenue is #uaranteed costs for health care+ the and the patient population least administratie num.er is fixed 0Austin 3 paper'ork+ and coer 4etle+ 5&156! In addition+ preentie care if proiders use less in 0Barsukie'ic+ 0Barsukie'ic+ 2affel+ 3 serices than the 2affel+ 5&1&6! Ho'eer+ capitated fee+ they are HM"s also restrict direct paid each month to coer access to specialists .y the cost of care+ they re/uirin# referrals .y a keep the difference! P)P+ re/uirin# patients to )onersely+ if care costs see a proider in the exceed the contracted HM" net'ork+ and often amount+ then the proider not coerin# more costly must assume that procedures or care financial risk+ 'hich puts options+ .ecause care is proiders at a mana#ed to control disadanta#e if they care excessie or unnecessary for a sicker patient care! Proiders #ain if population 0Austin 3
How does the model affe#t ro$iders? &n#lude ros and #ons'
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Name: Baraah El-Haik
&ndemnit!
Health Insurance Matrix HCS/235 Version 4
HM" Act of 1$,8+ 'hich re/uired that companies that offered health insurance and employed more than 5< employees include an HM" option! =he la' also supplied startup su.sidies for these health plans 0Barsukie'ic+ 2affel+ 3 2affel+ 5&1&6!
2affel+ 5&1&6! In staff model HM"s+ such as (aiser Permanente+ proiders are salaried+ .ut this arran#ement is the exception+ not the norm!
,89 for family coera#e in 5&&$! =he employee+ or .eneficiary+ paid the difference! =hen+ the health insurance company pays the proider directly!
specialty care 0Barsukie'ic+ 2affel+ 3 2affel+ 5&1&6!
they proide less care 0Austin 3 4etle+ 5&156! =his incentie could affect patient-proider trust!
4etle+ 5&156! HM"s also restrict the coered serices+ 'hich limits autonomy in medical decision-makin#!
An indemnity health insurance plan is traditional health insurance that has .een around for oer <& years! =he name comes from the ori#inal purpose: the idea 'as to reim.urse 0or indemnify6 people for the portion of medical .ills that inoles an unaccepta.le or un.eara.le
Indemnity insurance is a retrospectie payment system> this method is considered a fee-for serice payment method! =his methodolo#y inoles insurance companies and other third parties makin# payments after the proider has rendered a serice+ .ased on 'hat the
It is a fee-forserice plan+ 'hich means the insurers pay for medical serices once they hae .een rendered! Most plans come 'ith an annual coinsurance maximum and once the insured meets this amount+ 'hich aries dependin# on the plan+ the insurance company 'ill pay 1&& percent of the medical costs for the rest of the
Indemnity users hae open access structure+ 'hile these plans do re/uire that a su.scri.er select a Primary care Physician these plans do not re/uire that care .e coordinated .y the P)P! A su.scri.er may directly access specialists in a #ien carrier net'ork 'ithout hain# to first clear their P)P!
=he primary .enefit of an indemnity plan is the freedom the insured has to pick the doctor or facility of his choice! =his contrasts 'ith the 'ay mana#ed care 'orks+ in 'hich selectin# an out-of-net'ork proider results in either no coera#e or increased costs to the insured! Because indemnity policies do not inole a proider net'ork+ there is no a#reement .et'een proiders and the insurance company to proide care at specific rates! =hus+ the costs for serice can .e hi#her+ and a patient may .e re/uired to coer costs .eyond 'hat is considered
=his plan is #ood for proiders since they are not re/uired to .e in the proider net'ork in order for a patient to .e a.le to schedule to see them+ this also allo's them not to .e dictated on the serices that they can proide for their patient! Patients mi#ht only .e reim.ursed for a percenta#e of the serices rendered!
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Name: Baraah El-Haik
Consumer% dire#ted health lan
.oint%of% ser$i#e
loss! ;nderlyin# the concept .ehind this type of health insurance is that you+ the insured+ hae the choice as to 'hich health care professionals to see+ 'hen+ and in 'hat settin#+ as 'ell as 'hat dru#s and treatments you 'ould take! )onsumer directed health plans 0)@HPs6 emer#ed in the late 1$$&s! =hese products 'ere desi#ned to en#a#e consumers more directly in their health care purchases! =he conceptual model made cost and /uality information eident to the consumer+ usually throu#h the Internet+ thus creatin# a more efficient health care market! Point of serice first emer#ed in the 1$C&s!=he
Health Insurance Matrix HCS/235 Version 4
proider char#es for the serice rendered
calendar year!
?usual+ customary and reasona.le? 0;)26! In many cases+ the patient has to pay the proider directly+ then file paper'ork 'ith the insurance company for reim.ursement!
=his insurance plan is a prospectie payment plan rather than a insurance company! ince they hae to use their o'n money to pay for serices rendered they must look into findin# the .est price and only use their medical care 'hen they actually need it!
=he consumer health plan much like an HA+ the patient must pay a hi#h deducti.le for their serices .efore the insurance company 'ill pay for a portion of the serices! 4ith this plan the patient can also esta.lish a sain#s account that can also accrue interest 'hich is not taxa.le and can .e used for future health care needs!
=his insurance plan has many restrictions! =o /ualify the patient has to .e enrolled in an insurance plan 'ith a hi#h deducti.le+ cannot .e claimed .y anyone else+ and you cant hae any other type of insurance! =his plan is open in the sense that you can see 'ho you 'ant+ 'hich cause the patient to shop around for the .est price for the serice+ 'hich leads to competitie pricin#!
=his plan may .e #ood for patients that are in #ood health+ 'hich in turn allo's them to sae for future health issues that may come up!
In this model the proiders dont hae restrictions placed on them .y the insurance company! ince the patient is in char#e of their o'n proiders+ this means the proider must price their o'n serices makin# it competitie a#ainst other proiders in order to dra' patients in!
=his plan is retrospectie like a PP" or an
=his plan has co payments and deducti.les! After
P"s hae the #atekeeper model+ in 'hich the
=his model is #ood in sense that it offers lo' deducti.les and co payments+ yet it still
=his system is #ood fro proiders since it allo's them to see ne' patients
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Name: Baraah El-Haik
reason for the name is .ecause participants hae the freedom to choose the leel of .enefit they receie each and eery time they seek medical serices!
.referred ro$ider organi(ations
In the 1$,&s+ preferredproider or#aniations 0PP"s6 .e#an chan#in# the rules of fee-forserice care! PP"s steer employees to cooperatin# doctors and hospitals that hae a#reed to a predetermined plan for keepin# costs do'n! A PP" is similar to a health maintenance or#aniation+ .ut you pay for care 'hen it is receied rather than in adance!
HM"! =his plan does hae set rates dependin# on 'hether or not the proider is or isnt in the net'ork and the serices that are needed! If the proider is out of the net'ork the patient does hae to pay more out of pocket! =his plan is prospectie! Proiders in their o'n net'ork hae set rates+ 'hich if the proider is out of net'ork the patient has a hi#her rate! PP"s re/uire annual premiums!
Health Insurance Matrix HCS/235 Version 4
the deducti.les are met the insurance company 'ill then pay a set amount for serices and the patients pays a co pay! If the proider is out of net'ork the payment is hi#her!
physician 'ho controls access to the planDs proider net'ork! =he doctors in the plan are #enerally paid on a capitation .asis+ 'hich means they #et a set fee per person re#ardless of the amount of serice they perform!
has the flexi.ility to allo' the patient to see 'ho they 'ant! =his can also .e .ad in the sense that if they decide to see an out of net'ork proider+ their out of pocket cost 'ill also .e hi#her!
'ithout hain# to hae a referral from the primary care proider! =he do'nside may .e that the patient may not continue to see them is they are out of net'ork due to the out of pocket cost!
=he patient must pay an annual premium in order to hae access to the insurance company! =his is a third party+ 'hich is the #o .et'een for the patient and proider! 4hile they do ne#otiate lo' rates they do also allo' hi#her rate proiders! =hey also re/uire co pays and annual deducti.les!
PP"s hae an open-access model+ PP"s offer freedom of choice of proiders and #enerally hae had fe'er utiliation mana#ement constraints!
Pros: *ou 'ill not hae to choose and .e tied to any particular primary health care physician! *ou 'ill hae access to a lar#e num.er of facilities and physicians! *ou 'ill .e a.le to choose 'hateer physician or doctor to see for medical care! Hain# a referral to any specialist is not needed at all! 4hile usin# a participatin# proider you 'ill .e a.le to fix a ne#otiated amount 'hich 'ill .e less than the amount you 'ould hae to pay 'ithout the plan!
=his model proides the proiders 'ith a hi#h olume of patients into their offices due to the net'ork contract! In order to .e in this net'ork and het more patients their rates must .e lo'er to do so!
)ons: Almost al'ays there 'ill .e a deducti.le to .e met! =here 'ill .e a coinsurance amount after the deducti.le is met 'hich you 'ill hae to pay! PP" 'ill cost you more compared to other plans .ecause of the deducti.le+
%
Name: Baraah El-Haik
Health Insurance Matrix HCS/235 Version 4
co-insurance and other out-of-pocket costs!
Health sa$ings a##ount
Health ain#s Accounts 0HAs6 'ere created in 5&&8 so that indiiduals coered .y hi#h-deducti.le health plans could receie tax-preferred treatment of money saed for medical expenses! enerally+ an adult 'ho is coered .y a hi#h-deducti.le health plan 0and has no other first-dollar coera#e6 may esta.lish an HA!
HAs often operate on a concurrent payment system! HAs essentially represent a triple tax su.sidy for health care! All contri.utions to the HA are tax free! A certain amount of an employees #ross salary is 'ithheld and inested throu#h the HA!
4ith a health sain#s plan you hae to pay a hi#h deducti.le for the serices .efore the insurance company 'ill pay for a portion of it! =he patient can esta.lish this non taxa.le account for future health care needs!
)onsumers are not limited .y a health care #ate keeper decidin# 'hat medical care they can hae access to! )onsumers can take control of their o'n health! =he purchase of any health insurance policy is a hu#e decision
Pros: HAs can .e deposited into a health sain#s account and are taxdeducti.le! Any unused money at the end of the year rolls oer 0stays in your account6 to the next year! Interest earned is taxdeferred+ and if used to pay for /ualifyin# medical expenses+ tax-free! HAs can .e inherited! )ons: ince ones health is unpredicta.le+ this cushion may not accurately prepare for future expenses! Maintenance fees for HA accounts can .e hi#h! If the HA sain#s are not applied to appropriate medical expenses+ penalties and a 1&9 tax 'ill .e assessed!
=here are no restrictions for the proiders placed on them .y insurance companies! =his allo's the patient to shop around for the .est price for their health serices!
eferen#es Austin+ A!+ 3 4etle+ F! 05&156! The United States health car e system, combining busin ess, health, and delive ry ! 05nd ed!6! ;pper addle 2ier+ NG: Pearson Education! Barsukie'ic+ )! (!+ 2affel+ M! 4!+ 3 2affel+ N! (! 05&1&6! The U.S. health system: Origins and functions. 0Cth ed!6! Mason+ "H: )en#a#e earnin#!
