Health Insurance Matrix Essay

note When was the model first use?What kind of ante upment system is use, such as prospective, retrospective, or concurrent? Who pays for c be?What is the access structure, such as gatekeeper, open-access, and so forth? How does the model instill long-sufferings? Include pros and cons.How does the model affect suppliers? Include pros and cons.IndemnityIn 1932 the Ameri evict Medical Association (AMA) carry a strong position against prepaid group practices, favoring instead indemnity-type policy that protects the policyholder from expenses by reimbursement (Jones & Bartlett, two hundred7). As one of the first wellness policies in the U.S., indemnity intents atomic number 18 considered traditional health plans. Indemnity insurance plans arouse iii options. Two of them are reimbursement plans (Howell, R., 2014). One typically blankets 80 percent eyepatch the persevering covers 20. The other option covers 100 percent. The third option pays the see a certain measuri ng each day for a utmost number of days. Indemnity plans are fee-for-service plans (retrospective).With an indemnity plan the diligent pays for armorial bearing. later the patient must(prenominal) provide a choose in rove to be reimbursed.Indemnity plans are non-network based plans with open-access. This gives insured individuals flexibility when choosing doctors, hospitals, and health bang facilities. No first impart flush doctor (PCP) is necessary. No referrals are inevitable.Indemnity plans provide patients with flexibility and master over their aesculapian examination allot. No PCP must be selected. No referrals are needed to beget operate. The drawback however, is that patients must submit claims in order to receive reimbursement for go. This prat gain time. Indemnity plansonly reimburse services covered by the insurance agent. flow not covered ordain request well(p) payment from the patient.Providers can require the personifys for services up fron t to cover they are getting what they charge. Providers are not ask to help patients with the necessary paperwork needed for reimbursement. This potentially saves providers time and resources if they decide to ask for monetary resource in full before service. The drawback to indemnity plans is that patients whitethorn not restrain all the funds postulate to front the bill. Expensive services can detour patients from seeking make out.Consumer-directed health planConsumer-directed health plans (CDHP) were the result of public backlash against managed concern and the rise in health care expenditures (Bundorf,K. M., 2012). CDHPs were first introduced in the late 1990s. CDHPs aim to control costs by pose responsibility for health care decisions into the hands of patients.Patients with a CDHP are required to pay for aesculapian services in a fee-for-service type payment plan (retrospective). Patients pay for costs out of pocket until a level best out-of-pocket limit is met. The insurance company covers extra costs later the maximum limit is reached. The insurer fully reimburses the medical provider. Unless a claim is submitted (AET), in which case only a portion is reimbursed. With a CDHP the patient is required to pay 100 percent of the pharmaceutical and medical expenses. at one time the yearly deductible is met, the patient go away is only required to cover a certain percentage of costs.The percentage varies depending on the provider. Of course, there are plans that cover 100 percent of their in-network costs. Patients with a CDHP gain access to a network of providers that their insurance company rationalizes with. The patient is not required to choose a primary care atomic number 101, and is not required to obtain a referral to see a medical specialist for medical care (Aetna, 2012).CDHPs put out increase consumer control over health care dollars (Furlow, E., n.d.). Patients have weaken support tools (online, phone). They too have more power to make decisions. Alternatively, increased decision makingability allows patients to forgo care. This can delay diagnosing and treatment. Ultimately, reducing the effectiveness of the plan altogether.Potential for higher payment amounts at time of service. Alternatively, there is a potential for greater debt amounts. Larger debts will make it necessary for health care providers to be more high-pressure for collections. Providers will also encounter increased staff costs in order to follow-up with patients in advance of treatment, as well as in subsequent collection efforts (Fifth Third Bank, 2008).Point-of-serviceHealthPartners of Minneapolis pioneered point-of-service (POS) plans in 1961, but the belief took 25 years to get off the starting blocks (Dimmit, B., 1996). In 1986 CIGNA healthcare launched Flexcare, the first POS plan. By 1995 forty percent of employers with at least 200 employees offered POS plans. Providers within a point-of-service network are usually paid a capit ated fee. The fee is fixed and does not alter regardless of services rendered. POS plans operate using a prospective payment system. Insurance companies reimburse providers an concord amount that is decided before a patient receives services.Patients are liable for paid a co-payment when visiting a doctor. After the patient is seen, the provider submits claim forms to the insurer for the services rendered. Once the claims are processed the insurer will reimburse the provider (Austin & Wetle, 2012). If a patient goes out-of-network, they are required to pay the provider in full. Afterwards the patient can submit a claim for reimbursement.Point-of-service insurance plans utilize gatekeepers. This is the primary care physician for the insured individual. Patients are not required to obtain referrals from their primary care physician to seek medical care services from an out-of-network provider. Although it is recommended. If a patient goes out-of-network theyll typically have to pay the majority of costs. Unless the primary care provider makes a referral to an out-of-network provider, in which case, the medical plan will pick up the tab ( teensy-weensy employment Majority, n.d.).Patients can easily go out of network. They have geographic flexibility that allows them to access doctors virtually anywhere. Compared to an HMO, patients have more choices. On the other hand, deductibles can be costly (Gustke, C., 2013). Providers in-network require a small copay. Out-of-network providers require patients to appease a high deductible. POSs might not be worth it if you never use out-of-network providers. Out-of-network care requires patients to submit their own claims. Reimbursement can takes months to recover.POSs are very analogous to HMOs and PPOs. POS plans may have restrictive guidelines for health care providers. Some POS plans require the use of a primary care physician (PCP). PCPs are responsible for routine care, all referrals, obtaining precertification fo r in-network services, and option out paperwork for in-network care.Preferred provider organizationsPreferred provider organizations (PPO) originated in the 1970s. PPOs were created from the rules of fee-for-service care. PPOs steer employees to cooperating doctors and hospitals that have agreed to a predetermined plan for keeping costs down (Kiplinger, 2014).PPOs negotiate a contract with providers, specialists, hospitals, and pharmacies to create a unified network. The providers within the network agree on a set rate to provide health care services at a lower rate than they normally charge for services (Kiplinger, 2014). PPOs use a prospective and retrospective system. This is to ensure that the provider is only doing medically necessary tests and treatments for the injury being claimed, rather than onerous to gain a larger reimbursement.With a PPO the insured pay a deductible to the insurer. After the deductible is paid, the insurer then covers any additional medical expenses i ncurred. Preventative care services are not overpower to the deductible (Kiplinger, 2014). Some patients are required to make co-payments for certain services, or are required to cover a percentage of the total cost for medical servicesrendered. PPOs are open-access plans. PPOs allow patients to seek medical care with any provider, whether in-network or out-of-network. Patients are not required to obtain a referral, they are also not required to select a primary care physician.Patients with a PPO plan have the liberty to choose nearly any medical provider or facility they want for their medical services. If a patient seeks medical care within their network, their costs will be relatively low. Patients are not required to choose a primary care physician. They are also not required to go through their primary care physician to see a specialist if said specialist is in the PPO network. On the other hand, when a patient receives care from a provider outside of their PPO network, cost s can be higher and just abouttimes not covered at all.For in-network providers, PPOs guarantee a large amount of patients. Most patients would rather receive care in-network opposed to paying more for out-of-network. The prospect of a larger amount of patients enrolled in the PPO can generate more income for the provider. On the other hand a provider can lose capital if they are not fully reimbursed for medical services rendered, because they are not paid a capitated fee. Health savings accountHealth savings accounts (HSA) were signed into constabulary in December 2003. HSAs were created by a provision of the Medicare prescription(prenominal) Drug Improvement and Modernization Act (Stevens, S., 2005). HSAs are used in conjunction with high-deductible insurance plans to help offset the costs of medical expenses.Health savings accounts use a fee-for-service type payment plan (retrospective). When a patient receives medical care they are responsible for paying for the medical serv ices. Once their high deductible insurance maximum is met, the insurance company will then cover any additional medical expenses.With a HSA the patient is responsible for medical expenses. Since the patient is required to have a high-deductible insurance plan in order to qualify for a health savings account, their own personal money is used to pay for the coverage. On average a high deductible begins around $1,100 for individualsand $2,200 for family plans. bullion inside of an HSA is used to pay for expenses. This money is tax free and can be used to cover many other additional strung-out medical services.Health savings account plans are open-access. The patient has the freedom to choose their medical provider and facilities are their own discretion. Referrals are not required and there are no networks from which a patient must choose from. Patients with a HSA have the freedom to manage their accounts and finances themselves. Patients control how money is spent, and have the free dom to choose their place of care. Any money deposited into a HSA is theirs, even if an employer contributes to it. The patient is not required to pay taxes on any money that is in their HSA, or any money used on qualified medical expenses. Potential disadvantages for patients include unpredictability of unhealthiness and budget. If money withdrawn from the HSA is used for nonmedical expenses it will be taxed. Fines can also occur. A high deductible can be difficult for some to afford. Providers benefit from direct payments received from patients. Eliminating the middle man saves time and resources. On the other hand, this makes patients more consciousness about the services they use. Some patients may opt out of treatment to avoid expense.ReferencesAustin, A. & Wetle. V. (2012) The United States Health care body, Combining Business, Health, and Delivery. (2nd ed.) Upper Saddle River, NJ Pearson EducationBarsukiewicz, C.K., Raffel, M.W., & Raffel, N. K. (2010) The U.S. Health Sys tem Origins and Functions. (6th ed.) Mason, OH Cengage LearningBundorf, K. M. (2012) Consumer-Directed Health Plans Do They Deliver? Retrieved from http//www.rwjf.org/content/dam/ enkindle/reports/reports/2012/rwjf402405Aetna. (2012). Summary of Benefits and Coverage. Retrieved fromhttp//www.aetna.com/health-reform-connection/documents/SBC-Plansponsorflyer-Self-funded.pdfFurlow, E. (n.d.) Exploring Consumer-Directed Health pull off. Retrieved from https//www.ciab.com/WorkArea/DownloadAsset.aspx?id=318Fifth Third Bank. (2008). The Impact of Consumer-Directed Health Care on Providers. Retrieved from https//www.53.com/doc/cm/rc-cdh-provider-impact-10012008.pdfStevens, S. (2005). Pros and Cons of Health Savings Accounts. Retrieved from http//www.forbes.com/feeds/mstar/2004/04/08/mstar1_11_14978_132.htmlKiplinger. (2014) What to Know nigh Preferred-Provider Organizations. Retrieved from http//www.kiplinger.com/article/insurance/T027-C000-S001-preferred-provider-organizations.htmlDimmit t, B. (1996). Can Point-of-Service Go The Distance? Retrieved from http//av4kc7fg4g.search.serialssolutions.com.ezproxy.apollolibrary.com/?ctx_ver=Z39.88-2004&ctx_enc= entropy%3Aofi%2Fenc%3AUTF-8&rfr_id=infosid/summon.serialssolutions.com&rft_val_fmt=infoofi/fmtkevmtxjournal&rft.genre=article&rft.atitle=Can+point-of-service+go+the+distance%3F&rft.jtitle=Business+and+Health&rft.au=Dimmitt%2C+Barbara&rft.date=1996-08-01&rft.pub=Medical+Economics+Inc&rft.issn=0739-9413&rft.volume=14&rft.issue=8&rft.spage=42&rft.externalDocID=10005483mdict=en-USSmall Business Majority. (n.d.) Group Coverage Options. Retrieved from http//healthcoverageguide.org/part-one/group-coverage-options/Point-of-Service+Plans+%28POS%29Gutske, C. (2013) Pros and Cons of Health Insurance POS Plans. Retrieved from http//www.bankrate.com/finance/insurance/pros-cons-health-insurance-pos-plans.aspx