By having multiple options of coverage, affordable premiums and, in some cases nonexistent costs to the members. Furthermore, Medicare is constituted by four parts (A, B, C, D). Part A (Hospital Insurance) covers the hospital’s admissions to inpatient, home-health care agencies, hospices and nursing skilled facilities. No premium cost to members; however, some co-payments and a yearly deductible are required. Part B (Medical Insurance), cover included: primary physician visits and their services, some preventive services and other outpatient care. Part B is optional; nevertheless, a monthly premium as well as an annual deductible is required. Part C refers to two types of healthcare plans (Medicare Advantage and Medigap). Medicare “Advantage” aloud members the freedom to choose parts A and B through an approved private health insurance organization. On the other hand, “Medigap” is a supplement to Medicare,…
The Health Maintenance Organization (HMO) Program will coordinate with a specified group of doctors and hospitals to provide care. Employees are limited to only the specified groups or hospitals the HMO provides. The HMO plan offers no deductible, and copayment fees from $0 to $20 for visits depending on services performed. Employee also will be offered the option to seek their own healthcare providers outside the HMO program for an additional cost. A Preferred Provided Organization Program is also available to employees who want to visit their own doctor and hospital providers. There will a yearly family deductible of $500 and $250 for individual before any medical expenses are covered. The plans will pay 80% on care provided or performed within the preferred provider list. The plan will pay only $70 on care rendered outside the preferred provider…
PPO plans are the most popular plan that doctors, clinics, hospitals, and pharmacies contract with. One of the reasons that the PPO plans are so popular is because they pay the doctors a discounted fee for service based on their fee schedule. PPO plans offer a low premium that has a higher deductible or the other option is a high premium with a lower deductible. The patients are responsible to pay a copayment, and there is also a yearly deductible that the patient has to pay out of pocket. If a patient sees a doctor outside of the network without a referral, the plan will pay less and the patient is responsible for the remainder of the fee. Patients have their choice of providers, but if the patient goes to a out-of-network provider it will cost more. One thing to remember though is that all non-emergency services require pre-authorization.…
Review the Health Care Economics Issues HMO Simulation exercise posted on your student web page. Follow the Wk 4 WEB LINK “Understanding Economic Issues for HMO’s”. This exercise is for your learning experience only. Do not post any screen short from the exercise as part of your assignment.…
Looking over the Constructit Company they have 1000 employees working for them. The people at Constructit are willing to pay a maximum premium of $4,000 per person. The company has 550 men working for them and 450 women working for them. Out of all the employees 32% of them are involved in a great deal of physical activity during their work day,25% have moderate…
HMO which stands for Health Maintenance Organizations are licensed health plans that place providers, as well as the health plans, with dealing with HMO’s there is a risk of medical expenses. The downfall with HMO is that patients must stay inside their network and if the go outside the network they will have to pay out of pocket expenses. HMO is very limited; many patients don’t like limitations when it comes to their decision about their health.…
Managed care organizations can save money by providing lower prices through contracting large volumes of services and reducing the amount of hospitalizations (Getzen & Allen, 2011). This essay presents a scenario in which I am a representative of Castor Collins Health Plans responsible for maximizing profits and minimizing risks. Within my job description, I am advised to develop a comprehensive health insurance plan for two entities: ConstructIt and E – Editors. This essay explains the company’s employee demographics, health risk factors, premium amount the company is willing to pay, and what company I chose to offer a health insurance plan. Based upon my analysis of potential utilization, I will provide two reasons…
Understanding health care financial terms is a prerequisite for both academic and professional success. This assignment is intended to ensure you understand some of the basic terms used in this course.…
The cost of health care in the United States remains an important concern for American consumers. The challenges for controlling costs and providing a better health care system are various and complex. These challenges, in many cases, are in the realm of the Department of Health and Human Services (HHS) or other federal or state agencies (Department of Justice, 2012). Hospitals continue to team up with other facilities, insurers and for-profit companies, although the cause of the bump in M&A activity varies. While some hospitals cite financial problems, others join forces because of collaboration mandated under the Affordable Care Act and changing reimbursement models, according to Minnesota Public Radio (Caramenico, 2012).…
As a result of the Patient Protection and Affordable Care Act of 2010, beginning in October 2012, US hospitals will begin having their payments from Medicare affected by the Hospital Value-Based Purchasing Program. Essentially, this legislation will shift the way hospitals are reimbursed for services from a focus on quantity to a focus on quality. The following research study will examine the background of this legislation, how it is structured, and the pros and cons of this reform.…
Health Maintenance Organizations (HMOs) have an important role to their patients and their health care providers. Castor Collins Health Care Plan was found in the year of 1999, in Pantome. This particular HMO service provide health care insurance and health care services to a variety of physicians and hospitals. This company used the capitation idea for compensation to pay its health care providers. Castor Collins is currently serving 100,000 members, throughout Pantome, and is looking for ways to increase the their numbers.…
A large misconception associated with this concept is that pricing makes a small difference in overall profitability. Studies have demonstrated that the recovery rate (financial return a hospital expects for every dollar of rate increase) of those who completed strategic pricing had a recovery rate of 15.5% compared to the method of increasing across-the-board (13.5%). The contracts negotiated show magnitude in profitability, however, other factors are a considerable factor, and strategic pricing aids in defensibility when adverse things happen (Cleverley, 2008).…
Maintenance Organizations ("HMO"). The primary emphasis and, for…
References: Davis, K., Collins, K., & Morris, C. (2006). Managed Care: Promise and Concerns. Retrieved on August 25, 2010, from http://content.healthaffairs.org/cgi/reprint/13/4/178.pdf…
This can be set up differently according to the service provided (by diagnosis, by procedure, etc.) but will always set the reimbursement rate before the service is done, typically annually. The Centers for Medicare & Medicaid Services (CMS) uses this system for reimbursement, but has many different variations set up for the type of care provided. Hospital, skilled nursing facilities, outpatient centers, home health agencies, will all have a specific PPS set up for them (Centers for Medicare & Medicaid Services,…