Chapter 13 - Other Healthcare Providers Flashcards
Health Maintenance Organization (HMO)
- Service organization
- Membership based
- Providers are prepaid - typical arrangement would be a capitation system
- Network of prepaid providers
- Primary care physician that oversees care provided
- Gatekeeper system that controls access to physicians and specialists
- Other healthcare providers
- Preventive care designed to reduce cost by early detection
- Co-payments provided to make doctor visits more accessible
- Managed care attempts to balance are with cost
- Emergency care is provided in or out of network if necessary
- Traditionally a closed panel system with limited access to physicians
Preferred Provider Organization (PPO)
- A traditional insurance program
- Negotiates with providers for a prearranged discount
- Savings from discounts are passed on to the customer by reduced premiums
- Steers the insured to a network, but pays a higher rate within the network
Point of Service (POS)
Not affordable
The HMO response to the PPO
Provides coverage in or out of network
Affordable Care Act
Qualified Health Plan - certified by the affordable care act
Eligibility - must meet all the following:
- American citizen and state resident
- not incarcerated
- household income between 100% - 400% of Federal Poverty Level
Metal Plans - standard plans sold in exchange (co-insurance):
- Bronze 60%
- Silver 70%
- Gold 80%
- Platinum 90%
Agents:
- represent the insurance industry and assist consumers
- must register and complete annual training
Navigators:
- funded through the federal government to assist consumers
- must complete training, pass an exam, and maintain continuing education
Health Savings Account (HSA)
An account that allows the individual to pay medical expenses tax free
Must own a qualified high deductible health plan (HDHP) to qualify for an HSA
Flexible Savings Account (FSA)
Similar to the HSA tax breaks
Original was a “use it or lose it” plan each year
Some allow for a limited amount to be carried over each year
Workers compensation
No fault system
Exclusive remedy
Benefits:
- medical - unlimited
- disability - 2/3 of average weekly pay
- survivor (death) benefits
- Rehabilitation
Compulsory
