PROVIDERS OF HEALTHCARE PLANS

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Author:
sirinvictus
ID:
305495
Filename:
PROVIDERS OF HEALTHCARE PLANS
Updated:
2015-07-21 16:06:18
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PLANS
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PROVIDERS OF HEALTH CARE PLANS
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  1. Categories of healthcare plan providers
    • Service Providers
    • Commercial Insurers
    • Self Funded
    • The Government
  2. Distinguishing features
    • Profit or non-profit
    • Who receives the benefits
    • Choice of physicians and hospitals
  3. Service Providers
    Blue Cross Blue Shield - contract is between the provider of health care (hospital/doctors) and the Blues.

    Pay is on Service basis - payments directly to the doctors & hospitals, the providers of the health care

    Individuals are called MEMBERS and never directly receive benefit payments.
  4. Service Providers (2)
    Health Maintenance Organizations (HMO)- organize and deliver the actual healthcare on a prepaid basis in a specific geographic areas known as the service area

    Reduce medical expenses by emphasizing ROUTINE health care by stressing prevention

    Can own medical facilities staffed with salaried physicians as well as contact with a network of physicians practicing independently. 

    Required to choose a PRIMARY CARE PHYSICIAN

    Must have a referral from primary care physician to see a specialist physician
  5. Service Providers (3)
    Preferred Provider Organizations (PPO)- Managed healthcare systems where the insurance company negotiates with physicians and hospitals to provide medical services on a prearranged "fee for service basis".  

    • Use of preferred porovider receive 100% payment
    • Other physicians and facilities the insurer will pay a reduced benefit

    Benefits of PPO

    • More choices of physicians than HMO
    • Physicians are not employees of PPO
    • PPO pay on SERVICE basis- agreed to in advance
    • NO primary care (gatekeeper) required
  6. Commercial Insurers
    Stock Insurers and Mutual Insurers: Organized for profit.  Contract is between the insured and the insurer.

    • Operate on reimbursement basis
    • Payable directly to the insured
    • May assign right of payment of benefits to the healthcare provider
  7. Self Funded
    Multiple Employer Trust (MET)- many smaller employers combine their resources to provide group health

    • A trust is established
    • Can be self funded or funded through insurance contracts
  8. Self Funded (2)
    Multiple Employer Welfare Arrangements (MEWAs) - one or more large employers combine resources to provide group health on a group basis
  9. Government
    Medicare

    • 65 and over, or who meet other special criteria
    • Federal government administered

    Medicaid

    • Financially impoverished and not able to pay for his/her medical needs
    • Combination of Federal & State Admin

    Tricare 

    • Members of the armed services, their families, (dependents) and survivors
    • Funded by the US Department of Defense

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