Is point of service a gatekeeper or open access

Health Insurance Matrix

HCS/235 Version 7

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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.

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References

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