Health insurance is a form of insurance that covers surgical, medical, dental expenses, and prescription drugs incurred by the insured. Health insurance and managed care involve paying and accessing health services instead of protecting against financial losses.
The basic health insurer does not cover the whole of one’s cost but shares the cost with you to a certain point where one cannot help himself or herself. The main point of health insurers is all medical expenses are paid by the payers (Van de Ven et al., 2008). There are different ways a company can share a cost with the one being insured, and this makes the main features of the health insurance plan. It includes your deductibles, coinsurance, and copayment. Certain affordability standards and other rules have to be met for the health insurance plan to be included in a government-run health insurance exchange. Under the Affordable Care Act (ACA), all American citizens were supposed to have health coverage qualified the so then called individual mandate before being suspended in 2019.
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There are various types of managed care organization models. They include;
Indemnity insurance is an insurance model that covers the insured, who are the policyholders, against financial losses from medical expenses. People covered by indemnity plans are allowed to get coverage from any licensed provider. The insurance company can compensate the insured for the cost incurred in medical coverage; however, there is no confirmed commitment except to pay the subscriber unless stated by the laws.
Another form of managed care organization is Preferred Provider Organization (PPO). It has a smaller panel of providers because of its terms and conditions for participation by the providers. A considerable discount is allowed on membership below their frequently charged rates from selected professionals partnered with the organization (Peter Kongstvedt, 2009). Preferred Provider Organizations are more expensive and have fewer restrictions, hence having the largest market share than the Home maintenance system but less expensive than traditional insurance. There are two types of Preferred Provider Organization: risk-bearing Preferred Provider Organization and rental Preferred Provider Organization.
Point-of-service plan (POS) is another managed care organization model that combines properties of Home maintenance system and indemnity health insurance plans and more the same as Preferred Provider Organization at some point (Peter Kongstvedt, 2009). Point-Of-Service plans are sometimes formed on a Home maintenance system; however, they can still take two other common forms. One of them is minimal cost-sharing if a member decides to stick to the Home maintenance system, and the other one is remarkably higher levels of cost if the member decides to go outside the Home maintenance system. The difference between in-network services and out-network services coverage ranges from 30% to 40%. Another type of Point-Of-Service plan is a triple-option plan with less cost-sharing when a Home maintenance system is used to use Preferred Provider Organization as a part of the plan. In this case, the cost-sharing amount is more when the Home maintenance system is used, however, closely following Preferred Provider Organization benefit design.
Health Maintenance Organizations (HMOs), like other managed care organizations, are unique in different ways. Home maintenance system largely manages utilization and quality greatly than Preferred Provider Organization does (Peter Kongstvedt, 2009). Point-Of-Service benefits cannot be offered by the Home maintenance system unless required by the state of emergency care. Benefits coverage in the Home maintenance system enacts when services are ministered by Home maintenance system providers in adherence to authorization guidelines and procedures from the Home maintenance system. The categories of Home maintenance systems are; open panel, closed panel, and network model.
References
Healthcare Insurance and Managed Care 4th edition. Peter R. Kongstvedt
Van de Ven, W. P., & Schut, F. T. (2008). Universal mandatory health insurance in the Netherlands: a model for the United States?. Health Affairs , 27 (3), 771-781.
