Health Insurance Matrix

Topics: Health insurance, Preferred provider organization, Health economics Pages: 8 (3146 words) Published: July 26, 2015
University of Phoenix Material

Health Insurance Matrix

As you learn about health care delivery in the United States, it is important to understand the various models of health insurance to develop a working knowledge as you progress through the course. The following matrix is designed to help you develop that knowledge and assist you in understanding how health care is financed and how health insurance influences patients and providers as important foundational information for your role as a future health care worker. Fill in the following matrix. Each box must contain responses between 50 and 100 words using complete sentences.

Include APA citations for the content you provide.

Origin: When was the model first used?
What kind of payment system is used, such as prospective, retrospective, or concurrent? Who pays for care?
What is the access structure, such as gatekeeper, open-access, and so forth? How does the model affect patients? Include pros and cons.
How does the model affect providers? Include pros and cons.
Health maintenance organization (HMO)
The idea and concepts of health maintenance organizations have been reported back to 1910, when the Western Clinic in Tacoma, WA offered plans to utilize their providers to lumber mills employees and owners with a premium of fifty cents a month. However, it was not until Dec. 29, 1973, that President Richard Nixon signed into law the Health Maintenance Organization Act of 1973, to provide the option of health insurance to all citizens of the United States. Health maintenance organizations use a prospective payment system in which providers within a specific network are paid a flat rate per member on a predetermined scale regardless of if services are not utilized or over utilized. According to (“Patient Advocate Foundation” 2012), “care can be provided in a larger geographic service area than would be possible with only one physician group. This network model offers the patient choice of physicians and managed costs” (managed care answer guide). Who pays on a health maintenance organization plan is typically determined by plan. An individual can privately pay the insurance company, who then pays the provider. However, typically HMOs are provided through an employer who determines the amount of coverage that they are willing to pay. The rest is deducted from the employee’s earnings and both are paid to the insurance company at cheaper rates than other insurance plans. Health maintenance organizations have a “gatekeeper” structure. A member must choose a primary care provider within a specific network of providers. All care for the member must first be sought through their chosen primary care provider. In the event that a specialist is needed the primary care provider will refer the patient to a specialist within the same network. Any out-of-network care that a patient seeks is not covered by the insurance provider. One of the most positive aspects of a health maintenance organization from a member’s stand point is the cost. HMOs are by far cheaper than any other insurance plans with a fixed monthly rate that usually does not change. On the other hand, a negative aspect of an HMO is having to stay within the provided network for all health care needs. One negative affect that network providers experience with an HMO is that the amount of time and services provided on a patient can exceed the predetermined spending amount for the patient, in which case the provider assumes the responsibility for any overages of care cost on a patient. A positive aspect of HMOs from a provider stand point is that if the cost of coverage on a patient is under the predetermined amount the provider keeps the difference in cost.

Indemnity plans were the first type of health plan in the United States dating back to the 15th century. According to “eHow” (2013), “Industrialist Henry Kaiser and Dr. Sidney Garfield created the first...

References: EHow. (2013). Retrieved from
Health Savings Account. (2013). In Wikipedia. Retrieved from
Patient Advocate Foundation. (2012). Retrieved from
The U.S. Government Accountability Office. (2006). Retrieved from
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