HCS235T week4 discussion
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School
University of Phoenix *
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Course
235T
Subject
Health Science
Date
Nov 24, 2024
Type
docx
Pages
4
Uploaded by PhoenixAssignmentHelp
Understanding the various models of health insurance in the United States is essential in helping you develop foundational health care knowledge for your role as a
health care administrator
.
Think about how health care is paid for or financed, the structure of the model (e.g., gatekeeper, open-access, or combination of both), and the benefits and the challenges for providers.
Choose 3 of the following types of health insurance plans. Provide a realistic scenario where each of these plans would be the best fit for a specific patient.
Health maintenance organization (HMO)
Preferred provider organization (PPO)
Point-of-service (POS)
Provider-sponsored organization (PSO)
High deductible health plans (HDHPs) and health savings accounts (HSAs)
.
Health maintenance organization (HMO) policies require a PCP to coordinate care on behalf of the patient. If the patient needs to see a specialist, a PCP referral will be required, and the specialist may need authorization before an office visit. Pros for HMO policies it has lower monthly premiums, lower deductibles, copays, and out-of-pocket maximums, and the provider cannot balance bill the patient. The cons of the HMO policy are that it is restricted to in-network providers only and may not cover certain medical services. There are exceptions in which the HMO policy may cover an out-of-network provider in an emergency or by not having a provider within a 25-mile radius to render services.
HMO policy is suited for an individual looking for affordability for medical services or a healthy
individual who mainly needs routine preventive care.
Preferred provider organization (PPO) policies don’t require a PCP to coordinate care or referrals
to specialists. This policy has the flexibility for patients to see in-network or out-of-network providers. Pros of the PPO policy are that it is less restrictive; the patient can see any provider in-
network or out-of-network in-state or out-of-state. The cons of the PPO policy are the higher premium and cost-sharing. Also, the patient will need to manage and coordinate their care. Furthermore, out-of-network providers can refuse to submit a claim to the insurance company; it’s the patient responsibility to submit an itemized bill to the insurance to receive payment for the provider.
PPO policy is suited for an individual who travels outside of the state frequently or has a chronic illness and needs the flexibility to see their choice of providers without the restriction of a referral from a PCP.
Point-of-service (POS) policy is a mixture of HMO and PPO policies. This policy needs a PCP to coordinate care and requires a referral to see a specialist but the flexibility to go out-of-
network if needed.
POS is suited for an individual with minor health issues who may need the coordination of care from a PCP and possibly travels since this policy has a nationwide network with the flexibility of
going out-network.
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