Loading...

Messages

Proposals

Stuck in your homework and missing deadline? Get urgent help in $10/Page with 24 hours deadline

Get Urgent Writing Help In Your Essays, Assignments, Homeworks, Dissertation, Thesis Or Coursework & Achieve A+ Grades.

Privacy Guaranteed - 100% Plagiarism Free Writing - Free Turnitin Report - Professional And Experienced Writers - 24/7 Online Support

What is a gatekeeper ppo

16/11/2021 Client: muhammad11 Deadline: 2 Day

Health Insurance Matrix

HCS/235 Version 7

1

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

Homework is Completed By:

Writer Writer Name Amount Client Comments & Rating
Instant Homework Helper

ONLINE

Instant Homework Helper

$36

She helped me in last minute in a very reasonable price. She is a lifesaver, I got A+ grade in my homework, I will surely hire her again for my next assignments, Thumbs Up!

Order & Get This Solution Within 3 Hours in $25/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 3 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 6 Hours in $20/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 6 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 12 Hours in $15/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 12 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

6 writers have sent their proposals to do this homework:

Top Writing Guru
Math Specialist
Financial Analyst
Accounting & Finance Mentor
Coursework Assignment Help
Instant Assignment Writer
Writer Writer Name Offer Chat
Top Writing Guru

ONLINE

Top Writing Guru

I am an academic and research writer with having an MBA degree in business and finance. I have written many business reports on several topics and am well aware of all academic referencing styles.

$42 Chat With Writer
Math Specialist

ONLINE

Math Specialist

I am an elite class writer with more than 6 years of experience as an academic writer. I will provide you the 100 percent original and plagiarism-free content.

$30 Chat With Writer
Financial Analyst

ONLINE

Financial Analyst

I reckon that I can perfectly carry this project for you! I am a research writer and have been writing academic papers, business reports, plans, literature review, reports and others for the past 1 decade.

$25 Chat With Writer
Accounting & Finance Mentor

ONLINE

Accounting & Finance Mentor

I have worked on wide variety of research papers including; Analytical research paper, Argumentative research paper, Interpretative research, experimental research etc.

$48 Chat With Writer
Coursework Assignment Help

ONLINE

Coursework Assignment Help

I have read your project description carefully and you will get plagiarism free writing according to your requirements. Thank You

$34 Chat With Writer
Instant Assignment Writer

ONLINE

Instant Assignment Writer

I find your project quite stimulating and related to my profession. I can surely contribute you with your project.

$50 Chat With Writer

Let our expert academic writers to help you in achieving a+ grades in your homework, assignment, quiz or exam.

Similar Homework Questions

Beauty and the beast jeanne-marie leprince de beaumont analysis - Stanford prison experiment timeline - PowerPoint presentation - What is inappropriate communication - Net present value tutor2u - Mohr pipette vs serological pipette - Experience plans early childhood - Advantages and disadvantages of hitech act - How did cooper onyett drown - Medication dosage calculation worksheets - Microstrip t junction power divider - Please check for citations errors and grammar errors - Signals and systems laboratory with matlab pdf - 【(+97•15-2•730-•5642) Abortion Pills in Dubai|Abu Dhabi|Alain|Sharjah|RAK city|(Surgical Abortion in UAE)-mifepristone200mg & Misoprostol 200mcg Available in Dubai|Abu Dhabi-ipills in Dubai & Cost of Cytotec in Dubai| Abu Dhabi. - Why did robert frost wrote fire and ice - Bus 475 week 3 individual assignment - Declaration of arbroath lyrics - Presentation on social change - Ece 3567 - The danger of a single story ted talk summary - Multi trunk strawberry tree - Rabbits and wolves simulation - Free camping wagait beach - 2x 3y 12 solve for y in terms of x - Mrs donovan's dog questions and answers - Han emperors in china worksheet answers - Balancing equations worksheet chemistry - Oxygen gas within a piston cylinder assembly undergoes - Critical Reflection Essays - How many words for a 10 minute presentation - Business continuity plan and disaster recovery plan - Tina jones musculoskeletal objective data - Fun home chapter 1 pdf - Business Intelligence - What to write in a logbook - Edexcel epq dissertation examples - Microsoft Word Document 5 - Times they are a changin - Match the graphs with their parametric equations - STATISTICS TIMED EXAM NOW! DUE IN 1.5 HOURS - Owner of koi bubble tea - How to cite a guest speaker - The dominant area of study for the neobehaviorists was - At the edge of the orchard discussion questions - Adobe analytics keyword unavailable - Operations management simulation process analytics solutions - Mgmt - Parts of speech magic square answers - 510 assignment answer in english - Business management mcqs with answers - Read 2 articles and answer questions - Accounting ethics - Human effects on the biosphere - Synthesis of trans cinnamic acid from benzaldehyde and malonic acid - Worm and distributed denial of service ddos agent infestation - Mcgraw hill connect organizational behavior - Acel leadership capability framework - Gmdss radio log book pdf - How to apply ion boardroom theme - Homework Topic 2 - St james pharmacy woolwich - Electric field hockey activity worksheet answers - WK8 10-13 - Econ 3100 - ACG4342 - Writing Project - Part 3 - The yellow ribbon story by pete hamill summary - Delivering customer value and satisfaction in marketing - The thinker's guide to the art of socratic questioning pdf - Which promotional activity will sell the most products - Annotated bibliography ama - Existentialism and human emotions summary - Cca tax shield formula cpa - Dunkin donuts organizational design - Is there any way to download music to mp3 from a video to YouTube? - Halal kfc in wolverhampton - Racing pigeon ring list 2020 - Strategic management of apple company pdf - Older Adults Patient Education Issues Essay and Interview - Writing Assignment - 1 - Antibiotic resistance can we ever win answer key - Ermogenous v greek orthodox community summary - 1699 cook rd crossville tn - Quantitative techniques in management - Theory based on human properties - What nfl player has sickle cell anemia - Dream chocolate company choosing a costing system answers - Executive summary for project report example - Redox titration calculations questions - Max mara chatswood chase - Trivial pursuit bet you know it argos - Business Strategies - Change management courses brisbane - 3 day food diary assignment - Mark mcgwire vortex power bat for sale - Brüel & kjaer 2204 sound level meter - Light fixture cable hangers - Rational team concert client - Current market conditions competitive analysis paper - Ipv6 implementation in india - Resistor colour code calculator