Medical plans USA

Medical plans USA

Historically, there have been four basic  medical plans are available in USA, each type having unique characteristics. 








There are four types of Medical plans in usa:

·         Indemnity plans

·         Health Maintenance Organisation(HMO)

·         Point of Service Plans(POS)

·         Preferred Provider Organisation(PPO)

Today’s plans include multiple features and are hybrids of these four basic plan types. This is normally the case even if one of these historical titles is included in the name of the plan. It is still important to learn the basic characteristics of each type of plan.

1). Indemnity Plans: - Indemnity plans are earliest forms of medical plan. Originally, plans were designed to indemnity, or fully reimburse, a person seeking medical coverage. Meaning- early indemnity plans covered almost everything. This, of course, is very expensive and not practical in modern times. So indemnity plan began to include restrictions and cost sharing components. We now think of indemnity plans as having the following features.

           

·         Freedom of choice to see any doctor or use any hospital

·         Deductibles

·         Co-insurance

·         Reasonable and Customary

·         Out-of-Pocket Maximum

·         Lifetime Maximum

·         Self-referral for specialists – no primary care physicians

·         Pre—certification

·         Any surgery, second surgical options – requirements to obtain an opinion to a second doctor prior to.

2). Health Maintenance Organisation (HMO):-

The HMO act of 1973 gave birth to one to the mostly highly debated types of medical plans existing today. The goal of the creation of HMO plans was to help control rising health costs and to introduce a new philosophical approach. The result is a type of plan that includes several restrictions, or less freedom of choice, and a lower cost. Today, we think of an HMO as having the following features.

·         Use of a Managed Care Network – medical care is only covered if it is provided by a doctor or hospital within the specific network.

·         No coverage for out-of-network care

·         Primary Care Physician

·         Co-payments

·         Preventive care covered – sometimes at 100%

HMO plans are very restrictive. The only type of care covered is in-network care. With the exception of emergencies, no care outside of the network will be covered. There are also restrictions within the network. An individual cannot see a specialist for care without obtaining a proper referral from his/her designated PCP.

3). Point of Service Plans (POS):-

Many people desire neither the freedom of choice and high cost of indemnity plans nor the restrictions and lower costs of an HMO plan. A point of service (POS) plan incorporated characteristics of both an indemnity plan and an HMO plan. Because of this, a POS plan is sometimes informally referred to as a “schizophrenic plan’’ because it seems to reflect two different personalities depend on if care is sought in-network or out-of-network, feature of a POS include.

·         Use of Managed Care network

·         Coverage for care outside of the network

·         Freedom to see any doctor of hospital with a financial incentive to use in-network care.

·         Co-payments for in-network care

·         PCPs required for in-network care

·         Preventive care covered in-network

·         Deductibles for out-of-network care

·         Co-insurance for out-of-network care

·         Reasonable & Customary for out-of-network care

·         Self-referral for specialists – no primary care physicians for out-of-network care.

In other words, when care is obtained in-network, a POS looks and functions just like an HMO. When care is obtained from an out-of-network provider, a POS looks and functions just like an indemnity plan. A person can choose how they wish to seek care at point they need the service provided.

Individuals preferred POS plans because of the flexibility to seek care inside or outside of the network and still have costs covered by the plan. Generally speaking, this type of plan appeals to individuals who do not mind provider restrictions in exchange for a lower overall cost, but still want the option to go to the provider of their choice when desired.

4). Preferred Provider Organisation (PPO): -

Like POS plan,PPO plans provide flexibility by covering medical care both inside and outside of a network. PPOs are different from POSs in the way the plans are structured. For a PPO plan,in-network care and out-of-network care will contain similar features with in-network care having lower costs. PPO features include:

·         No PCP required for in or out-of-network care

·         Use of a Managed Care Network

·         Coverage for care outside of the network

·         Coinsurance for in-network care.

·         Freedom to see any doctor or hospital with a financial incentive to use in- network care

·         Deductibles for in-network care.

·         Self-Referral for specialists – no primary care physicians for in-network care.

·         Deductibles for out-of-network care

·         Co-insurance for out-of-network care

·         Reasonable & Customary for out and in network care

·         Self-referral for specialists – no primary care physicians for out-of-network care.

For more details about USA healthcare system.

References | http://dotnettec.com/understand-us-healthcare-system/

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Purpose

The health care industry is one of the largest industries in the world, and it has a direct effect on the quality of life of people in each country. Health care (or healthcare) is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers. The health care industry, or medical industry, is a sector that provides goods and services to treat patients with curative, preventive, rehabilitative or palliative care.

All country has different health medical plans .The modern health care sector is divided into many sub-sectors, and depends on interdisciplinary teams of trained professionals and paraprofessionals to meet health needs of individuals and populations. The health care industry is one of the world's largest and fastest-growing industries and forms an enormous part of a country's economy.