Question

1. Discuss the differences and similarities of the various third party insurance plans. Please make sure that you include in your essay the different managed care plans.

Answer 1

Ans) Commercial Health Insurance is a third-party insurance plan that covers medical expenses of privatehealth insurance and employer group health insurance.

- Premiums and benefits vary according to thetype of plan. Group health insurance premiums are usually lower than private health insurance.

- Private health insurance regulated by individual states and Group health insurance available through employers and other organizations of the premium cost paid by employers.

- Blue Cross and Blue Shield a non-profitprepaid health care plan that has features different from other commercial healthcare plans groupsinclusive to maintain negotiable contracts with providers of care, state law forbids cancelling coveragefor an individual because or poor health or payments have exceeded the average, must obtain approval from their state Insurance Commissioner for any rate increases and/or benefit change that affect theirmembers within the state and must allow conversion from group to individual coverage and guaranteeability of membership from one local plan to another when a change in residency moves a policyholderinto another area served by a different BCBS company. Tricare is a third-party healthcare plan for activeduty members of the military and their qualified family members, retirees and their family, and survivorsof all uniformed services who are not eligible for Medicare.

- Lastly, Workers’ Compensation Insurance
provides benefits to an employee injured while working within the scope of the job description, hurtwhile performing duties required or develop a disorder that can be directly related to employment.Workers’ Compensation can also be related to injury away from company property if duties pertained to the job.

- Incorporating Manage Care has benefitted the employees and employers, more comprehensivecoverage, expanded healthcare coverage, appropriated medical treatment, coordination of medicaltreatment and services and no out-of- pocket cost. Health Maintenance Organization (HMO) is a managecare plan offering members a range of health benefits and preventive care for a set monthly charge.

- The healthcare provider and facility must be in the network, unless it’s an emergency. The provider isselected from a list provided. Most HMO require a small copay for each visit to a doctor or facility and some do not, but the premiums are higher.

- Point of Service (POS) managed care plan optional withinmany HMO plans that allow members to refer themselves outside the network and if the service iscovered by the plan, a co-insurance is paid.

- If the primary care provider makes the referral outside of thenetwork, the plan pays all or most of the bill. Preferred Provider Organization (PPO) managed care plancloset to a fee-for-service.

- The physician, hospitals, and other care providers agree to accept lowercharges from the insurer for their services to be part of PPO network. Individuals outside the networkare required to meet a deductible.

- High Deductible Plan (HDP) also called Consumer Directed HealthPlans (CDAP) are becoming a gradual widespread as employers and health plans are shifting morepayment responsibility to the plan member.

- A high deductible plan with a large deductible that a familyor patient is financially responsible for that must be met for insurance to kick in.Medicare is a federal healthcare plan for an individual 65 or older, End Stage Renal Disease withpermanent kidney failure requiring dialysis or renal transplant and certain young children withdisabilities.

- Medicare has a Part A covers Hospital insurance and Part B covers Medicare insurance. Part Ais premium free if 65 or older, you or your spouse worked and paid Medicare taxes for at least 10 years,receiving benefits from Social Security or the Railroad Retirement Board and you are your spouse hadMedicare-covered government employment.

- Medicare benefits has no upper dollar limit if you usemedical services that Medicare covers that are medically necessary. However, hospital reserve dayscomes with a limit for some individuals. If you need to stay in the hospital for more than 90 days with thesame illness or injury, you have the option of using some of your 60 lifetime reserve days and once the60 days are depleted, the individual pays the hospital’s full daily charge if you need to stay for more than90 days in a benefit period with exception for services covered under Medicare Part B. Medicare isregulated by The Center for Medicare and Medicaid Services (CMS) a branch of the Department ofHealth and Human Services (HHS) the federal agency that runs the Medicare program. Medicaid is afederal-state program that varies from state to state within federal guidelines.

- The Center for Medicareand Medicaid Services monitors Medicaid programs offered by each state. Medicaid serves people withlow-income of every age and limited assets. Medicaid coverage covers older adults, people withdisabilities, children, pregnant people and parents and/or caretakers with children. Some states help individuals with limited income and assets in need of nursing home care, long-term care and home health services.

- Each state has their own financial eligibility guideline to be eligible for Medicaidcoverage base on your income and assets below a certain amount to qualify.

- Some states offer a Medicaid medically needy program with incomes over their state’s eligibility requirements, a programallowing an individual to deduct medical expenses from their income to qualify for Medicaid.