1. Understand the 3 main types of cost sharing in private insurance and how they function.
The three types of cost sharing are: Copayments, Coinsurance, and Deductibles.
Copayments are the amount that must be paid out of pocket for health services, after the deductible has been paid (a fixed amount).
Coinsurance is the percentage of the costs for a health care service that the insured must pay, after the deductible is paid for (typically 20%).
A deductible is the amount the insured must pay before any benefits by the plan are payable.
2. Research and understand the 5 main types of Private Insurance
The five main types of private insurance are: HMO’s (Health maintenance organizations), PPO’s (Preferred provider organizations), High-deductible
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The purpose of this act, was to regulate the privileges of HMO’s. It allowed for IPA-HMO’s to be used throughout the nation, but placed restrictions on what they could/couldn’t cover.
14. Discuss managed care in terms of organization (MCOs, HMOs, PPOs, IPAs).
MCO’s (managed care organization) and HMO’s are essentially the same thing. They allow for provision of care to a group of insured members.
PPO’s permit out-of-network appointments sans referrals and give the freedom to choose from several providers.
IPA’s are a group of physicians that are contracted with an HMO/MCO plan to care for HMO/MCO patients. (Ex: Kaiser is not an IPA-HMO provider, where Sigma is)
15. Describe the main characteristics of a health maintenance organization.
HMO’s are a very affordable option in cost-sharing, relative to insurance, as well as low copays. Due to this, they require the selection of a primary care physician, who acts as a gatekeeper, meaning the insured is limited in choice when seeing providers and requires referrals from their PCP. This type of plan also has frequent usage of utilization management.
16. Discuss the utilization control methods of gatekeeping and the types of utilization review in terms of how they try to contain