Health Insurance Matrix

Health Insurance Matrix




Health Insurance Matrix

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) This is a kind of insurance model where individuals or employers pay a monthly charge for healthcare. This is a fixed monthly fee as opposed to the variable fee patients pay every time they visit a health facility. The monthly fee is constant regardless of the kind of service patients receive at the hospital. The health services are provided by physicians or healthcare personnel contracted by the Health Maintenance Organization. This is financed by the monthly payments provided by the employee or the employer for the employee and Copayments. Copayments are payments made upon getting a healthcare service. Copayments are paid every time a prescription is given. The holder normally pays the Copayments. HMO is a gatekeeper kind of a health facility. It caters for only necessary medical treatment, drug prescription and services through utilization review. Health Maintenance Organization only allows those who have prescribed to get medical services from doctors and healthcare providers in the network’s plan. If an individual seeks medical services out of the network, all the expenses will be channeled to them and thus making this a gatekeeper model. Whenever a health care provider or a facility isn’t in a position to offer the service needed, the health care provider can refer the patient to a non HMO approved facility. This system allows for medically necessary drug prescription and services and thus helping the regulators in provisioning of regulation for the scheme for people who may want all medical services in the facility. Health providers are sometimes not in a position to offer their services and thus forcing them to incur more expenses in covering the cost for those who are covered by this. Some of these health services that are not available at the facility could include emergency health services. The law requires HMOs to have sufficient facilities and personnel within a specified limit distance from homes or facilities. All the funds to do this aren’t readily available and poses a challenge.
Preferred Provider Model Preferred Provider Model is a kind of Medicare plan where private firms offer health insurance. Those seeking healthcare services while in this plan pay less while seeking medication from doctors who are in this network. If one seek’s healthcare services from doctors outside the plan, they get to pay more. Preferred Provider Model has a chain of doctors who provide these healthcare services and they get to pay less. The care is financed through monthly premiums paid to private insurance companies offering this health cover scheme. There also exist a copayments attached to the cover and deductibles paid with penalties accompanying the cover. In relation to financing, there is also an adjustment amount deduction going towards the scheme. PPO typically permits its members to induce health care from any health care facility or doctor or alternative health care suppliers among or while not its network set up as a result of the set up contains a network of doctors and alternative health care facilities. It offers the holders the pliability to go to any however those not within the set up’s network can continually value over those among the network plan. it’s thus AN open access quite medical aid. In PPO the holders don’t get to select a selected medical aid medical practitioner to produce medical facilities. This protects the suppliers the value of recruiting new doctors each time a member’s doctor equal or retires from the set up. The doctors may handle completely different patient and no specific patient therefore sanctioning flexibility in commission provision by the suppliers. The main challenge in PPO suppliers is that in cases wherever doctor’s are committed at their centers of work, inconveniences could occur at different centers with inadequate doctors or wherever the quantity of these seeking medical attention surpasses the men of the accessible doctors in those health centers (Rothwell, W. J., Hohne, C. K., & King, S. B. 2018). Doctors might also be needed to commute from one clinic to a different in alternative geographical areas since no one is allotted a primary doctor. The travel could generally delay service provision.
Point-of-Service Model A point-of-service set up (POS) could be a healthcare system that integrates each HMO and PPO systems. Participants get a plan-network doctor as their primary medical personnel like in health insurance however also can look for outside-network medical services like in PPO although they’ll pay additional price unless referred by the first medical personnel. It is settled on a cost-sharing mechanism entailing premium contributions, copayments, out-of –pocket-maximum and generally co-insurance. The value is basically shared between the leader and conjointly the workers majorly through premium contribution. Co-payments and con-insurance are modes of sharing the price at the time of service. The higher cost us the estimate when seeing health and medical services from those that are not in the network (Piper, 2016) This model. Point-of-Service Model, incorporates both gatekeeper and open access structure. Gatekeeper structure arises from HMO model perspectives that keeps primary medical service provider while open access structure springs from PPO model as it permits other plan medication though being more expensive. This proves POS to be a mix of the two. POS plans provide countrywide coverage so available to get clients from oftentimes traveling patients across the country. There are no deductibles for internetwork services therefore making it enticing to many people unlike PPOs. The premiums payable vary between the higher PPOs and the significantly lower premiums of health maintenance making it favorable. Exorbitantly high deductibles are charged y the POS in out-of-network services to policy holders. Patients will have to meet the whole cost from their pocket. As relating to this cost, it is discouraging to some policy holders and thus why they prefer Health Medical Maintenance because of their lower premiums payable.
Provider Sponsored Organization A provider-sponsored organization (PSO) is the managed health care acquiring and care provisioning firm with a number of hospitals, doctors and different health service suppliers. World Health Organization (WHO) offers full protection of the lives of their beneficiaries. PSOs square measure owned and goes past health service suppliers like doctors, hospitals and different health professionals but not insurance corporations. PSO is financed by a monthly payment by each of the beneficiaries who are subscribed to it. PSOs could be profit oriented or service oriented with minimal concern for profits. Some may be public while some private. The public ones charge relatively lower monthly payments than the private ones. The profit-oriented ones also charge a bit higher prices PSO is an open access kind of health care scheme since it allows patients to visit any health care facility with such a scheme and pay the fixed monthly charge. It offers no limitation to patients In terms of the physicians and facilities. Patients can therefore choose between public, private PSOs or for profit depending on the kind of services offered. Service providers under this model can get to offer their services to a number people countrywide as they are popular across the country and have many people signed to their services. Providers set their monthly income basing on patient’s income and therefore vary patient to patient and also depending on location making many people afford access to this service. A suitable health packed can be found for people in different demographics. Since there is a varying charge and considering that it is offered by both public and private, it is prone to abuse and misuse from every sector. Private entities could be charging more that they offer since most are for profit. Private entities overlook their core mandate of providing healthcare and focus on profits at the expense of their primary goal of better healthcare.
High Deductible Health Plans and Savings Options High Deductible Health Plan and Savings Options is a model of health policy from insurance firms with a higher deductible and significantly lower premium. Individual or a family should have a Health Savings Account qualified for HDHP as it usually covers preventive care prior to the deductibles but the expenses must be paid until the deductible is paid by the insured in full. HDHP is paid through deductibles, premiums and out-of-pocket maximum. 2016 deductibles are at least $1300 for a single person and $2600 for a family as retained from 2015 and the out-of-pocket maximum should not be more than $6550 for one individual. Double the amount for a family and is a little t than the 2015 amounts though lower than the limits of out-of-pocket maximum required by the ACA for all plans in 2016 (Dau-Schmidt, Finkin & Covington, 2016).  It is a gatekeeper kind of model as a result of it’s offered by specific insurance firms with their own policies coping with the HAS plans and HRA plans. The holders will solely get medical facilities from healthcare systems upon that their employers hold the health care scheme with. Otherwise owed most would be incurred for much more services. The Health savings account tied to HDHP theme reasonably} useful in serving to in payment of the premiums and deductibles therefore kind of relieving the policy holders the burden of direct money payment and additionally making certain monetary security to the facility providers. It eliminates the likelihood of unpaid services. This plan charges higher deductibles than HMOs, PPOs and POS and therefore is becoming unaffordable very many workers. For this reason, it makes workers opt for HMOs, POS or even PPOs. Out-of-pocket maximums are also significantly higher. This scheme is of comparatively higher than other schemes therefore hard to be maintained by a number of employers and mostly employees.


Dau-Schmidt, K. G., Finkin, M., & Covington, R. (2016). Legal protection for the individual employee. West Academic.

Piper, C. E. (2016). Healthcare Fraud Investigation Guidebook. CRC Press.

Rothwell, W. J., Hohne, C. K., & King, S. B. (2018). Human performance improvement: Building practitioner performance. Routledge.