Features of Private Payers and Consumer Driven Health Plans

The types of managed care are differentiated by definition, operation, structure, and information needs. `HMOs were the most common type of MCO until commercial insurance companies developed PPOs to compete with HMOs' (Douglas, 2003, p.331). `HMOs are business entities that either arrange for or provide health services to an enrolled population after prepayment of a fixed sum of money, called a premium' (Peden, 1998, p.78). There are three characteristics that an HMO must have. The first is a health care financing and delivery system that provides services for members in a particular geographic area. Second, is ensured access to a complete range of health care services, health maintenance, treatment, and routine checkups. Last, health care must be obtained from voluntary personnel that participate in the HMO. The five HMO models related to the participating physicians are the Staff

Another type of managed care program that was introduced is the Preferred Provider Organization (PPO). A PPO is comprised of a group of physicians, hospitals and other medical service providers who contract with employers, insurance companies or other plan sponsors. The PPO offers discounted pricing to these contracted organizations due to the high volume of business received. PPO’s typically have up-front cost sharing in the form of deductibles and/or co-insurance, which vary depending upon the actual plan chosen.

Regrettably, there is a downside of High Deductible Health Plans (HDHP), and that is the likelihood of higher expense later on if there is any cataclysmic medical issue with you or your family. With a High Deductible Health Insurance Plan, you run the risk of having higher out-of-pocket expenses. For example, a major medical issue warrant surgery, you would have to pay your deductible before the insurance company pays anything. This may cause you to forgo crucial health care needs; due to the high-deductible and out-of-pocket expenses you would occur. Lastly, if your monthly out-of-pocket expenses are high, this will enable you to have an advantageous use of your health savings account (HSA).

The main page of the website is titled “Health Plans and Benefits.” This page defines a group health plan as “an employee welfare benefit plan established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement, or otherwise” (“Health Plans and Benefits,” n.d., para. 1). Furthermore, the website highlights ERISA as an important regulation that protects the rights of plan participants and beneficiaries. Users can learn more about ERISA by clicking the link titled “Employee Retirement Income Security Act (ERISA).” In addition to ERISA, the site provides information about Employee Benefits Security Administration (EBSA). EBSA is responsible for regulating ERISA and providing both consumer information on health plans and compliance assistance for

I currently work for a hospital which is part of an academic medical center. It offers 3 health plan options to choose from. The first is the hospitals own medical plan which which is has features of an EPO, and can be categorized as a CDHP (Consumer Driven Health Plan). It has a higher monthly cost, but lower out-of-pocket costs when care is needed. It has a large network of providers including the hospital, and a network of providers who have partnered with the institution. You are not required to have a PCP, but it is recommended, you must use in-network providers, it has a HIA (Health Incentive Account) with wellness incentive funds available for members. The second is a POS plan from one of the larger Insurance companies with 2 tiers of in-network providers, lowest monthly cost, but a higher out-of-pocket cost when care is needed, until you meet the annual deductible amount. This has a Health Savings Account (HSA) attached, and you can have tax deductible contributions go to the fund, and wellness incentives funds can be deposited into the HSA. The third is an HMO plan with the highest monthly cost, but a lower out-of-pocket cost compared to the POS plan when care is needed. It also has an HIA attached as well.

Preferred provider organizations have also contracted with hospitals and physicians to provide health-care services. Unlike the case with an HMO, you do not have to go to these physicians. However, you will pay more if you go outside the list of preferred providers. PPO plans usually have a deductible, which is the amount that the insured must pay before the PPO begins to pay. When the PPO plan does start to pay, it will usually pay a percentage of the bill and you have to pay the remainder, which is called “coinsurance.” Most plans have an out-of-pocket maximum. This helps protect you from paying more than a certain amount per year. After you exceed the out-of-pocket maximum, the coinsurance percentage paid by the PPO increases to 100%. (www.ajmc.com)

If ever you've had to pay out-of-pocket for medical, dental, vision or prescription expenses, you likely either already had some money set aside or wish you had... That's where Healthcare Flexible Spending Accounts (HCFSA), Limited-Purpose Flexible Spending Accounts (LPFSA) and Health Savings Accounts (HSA) come in particularly handy. As a Benefits Administration Professional, I've become acquainted with the various types of accounts available to cover healthcare costs. The similarities and differences in these account structures will be covered in this essay.

The United States currently employs a multipayer system. The payers in this system include the government and private insurance companies., thus the collection of money for health care is a joint responsibility of both parties. Private insurance companies collect premiums and other payments from enrolled individuals and businesses. The government collects taxes from individuals and businesses. Regarding reimbursement, the private insurance industry reimburses providers for health care services delivered to privately insured individuals, while the government reimburses providers for health care services delivered to publicly insured individuals (e.g. people enrolled in Medicare, Medicaid, S-CHIP, or the VA).

care and end up with severe conditions that might have been prevented. Consumer-driven health care plans and Health Savings Accounts might turn out to be another cause for the rise of health care cost instead of the resolution.

In case you are unaware of what an HSA qualified plan is, it is it is an option that allows for a lower monthly premium because of a higher out-of-pocket exposure. So these are the plans that you hear about that carry to 3, 4 and $5000 plus deductibles. This particular class of plans allows for those who purchase them to open was called a Health Savings Account. A Health Savings Account allows qualified plan participants to put money away to pay for eligible medical expenses, free of any income taxes. If you are receiving your benefits through work and you have an HSA qualified plan, typically, your premiums would be taken out of your paycheck tax-free, if you’re buying an individual plan obviously you can’t have your premiums deducted are your paycheck. Those of you buying individual plans you’re able to write off your contributions to your HSA when you file your taxes. So, not quite as convenient as

There are many ways to educate your staffs, is to give them the option to choose between the defined-contribution plans, direct contracting, and consumer-driven a plan. However, more generous interpretation of consumer-driven plans than previously mentioned, and the national health insurance. For instance, under defined-contribution plans, employees typically choose from a variety of health care options, with a specified amount of the premium paid for by the employers. One way to insure your staffs is direct contracting which is large employer’s contract directly with integrated delivery systems or of health care providers capable of accepting a financial risk and delivering a full range of health care services. (Nowicki, p74 & 75.)

It’s a separate medical and disability reimbursement program which provides A 100% coverage for job-related injuries, illnesses or conditions arising out of and in the course of employment.

The Flexible Spending Account (FSA) is valuable to consumers, businesses, and policymakers it helps better assess returns on health care spending. If you have a health plan through employment, it can be beneficial to have a Flexible Spending Account (FSA) for copayments, deductibles, some prescription medication, and some durable medical equipment. Using an FSA can decrease your taxes that you pay. An FSA is an account an employee can put money into to pay for certain out-of-pocket health care costs, but you must use the money in an FSA within the plan year.

When individuals are searching for employment, they may certainly be interested in the compensation of the position, but something equally important to some job seekers are the benefits and total compensation package that employers may offer. An employee facing separation from employment or one of the other qualifying events must consider that it is not just their salary that they are losing, it may be their health care benefits for themselves and their family. Lawmakers saw the need to establish an incentive for employers to provide continued health care coverage after certain events that led to a loss of health coverage. Thus, Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985 (henceforth, COBRA) enables qualified

they authorize employees to take control of planning their health care spending through researching the information which allows them to be more judicious and thrifty with their health care spending. Granted there is the initial high cost due to deductible but over the long run the benefits are great due to no increase CDHPs 5 in health care costs if it’s done judiciously. When employees are more cost- and health conscious by being exposed unswervingly to the costs of their care, this will lower demand for care and, in turn, control premium growth. This is why preventative care is very important and these features have made consumer-directed plans progressively more attractive to