Editors Note: This is Part I of a two-part American health care guide. Today’s we focus on the different types of health care in the United States. Tomorrow we will highlights ways to get insured, even in difficult circumstances. We hope you find this useful and would love to have you tell us about your experiences, or even options and situations we may have overlooked. Use the comment field below to add your voice. After you’re done, visit our sister site, The Beehive, for more great ideas on how to live a healthier life and get care when you need it.
By Mike Lazear: PIC Current Producer
Almost all industrialized nations except for the United States have some form of universal health care. This means the government (and taxpayers) pay much of the bill for medical costs, covering all citizens. In the United States, however, private insurance groups, the patient, and to a small extent, the government pick up the tab. The government generally covers the elderly, disabled, poor, and military service families. In 2003 about 35% of individuals between the ages of 19 and 64 had no health insurance in the United States.
It’s a system that has been met with a lot of criticism in recent years. While Universal Health Care in the United States may come someday, you can educate yourself to make good choices when selecting a provider.
This guide will help connect you with resources where you can find affordable health care. Whether you are unemployed, have a pre-existing condition, a stay-at-home mom, or cannot easily afford health coverage, do not despair. There is a solution for you.
It is important that you do your research when deciding on the kind of health care fits you best. Because of the state of healthcare in the US, it is often difficult to make a decision. Never fear though, PIC Current is here to help!
First, let’s go over the different types of health care.
Managed Care
This is a technique that is used to help control the costs of health care. Often a group of health care providers are used to help enrollees connect with quality health care. There are usually high standards for selecting providers, which means that the enrollee does not necessarily get to choose which clinician to visit, or at least has some limitation in the matter. There are often some financial incentives for using preventative care techniques, such as visiting your doctor for a checkup.
While Managed Care sounds like a good solution for controlling the costs of health care, in reality it has failed to do so effectively in the United States. It has actually contributed to Higher Health Care costs, making it difficult for groups of some lower income levels to afford even basic care easily. It has also potentially driven up the prices of hospital stays, surgical procedures, and many other more serious health care needs.
Managed Care has it’s pros and cons, but it is a major part of the American Healthcare landscape today. A provider is anyone that provides health care under this system, and that can range from a clinic to primary care physician, or even a nurse. It is important to remember that as an enrollee, you are either entering into a contractual relationship with an organization that provides you with managed care, or you are receiving care from a provider.
For more information about Managed Care visit:
HMO
An HMO, or Health Maintenance Organization is essentially healthcare that is pre-paid. The enrollee pays a monthly premium which can vary depending on the type of coverage, and the HMO will cover their medical expenses. Actual fees at doctor’s offices tend to be very low for patients. Sometimes there is a small co-payment due at the time of the appointment, but this is usually in the realm of $5-$30, with the higher figures going to emergency-room visits.
HMOs have real advantages over other types of healthcare due to their:
1. Simplicity – You are covered as long as you pay your premiums, and your visits to the doctor are often no more complicated than presenting a card with your name on it.
2. Fixed Fees – These keep costs down by freezing the rate of a certain treatment.
3. Preventative Care – HMOs cover immunizations, physicals, and overall checkups.
4. Less Expensive – Typically, HMOs are less expensive than major medical plans
Still, there are downsides to HMOs. The often longer waiting times at doctor’s office and overall rising costs of HMOs make some people skeptical. It can also be difficult to see doctors outside the plan network, which limits your choices. There are, however a variety of HMOs which all have unique health care policies. You should research the specifics of each one if you are able to choose among them. Some examples include:
1. Aetna
3. Health Net
4. Wellpoint
5. Cigna
To learn more about HMO’s visit:
PPO
A Preferred Provider Organization is very similar to an HMO on the surface. The main difference is you have fewer limitations. With an HMO, it is only possible to see certain doctors and visit certain clinics. But with a PPO, you may see a wider range of doctors as long as they are within the same general network.
Like an HMO, you can just show your card to the receptionist and not have to fill out countless forms before seeing the doctor. This is a nice advantage.
The main drawback to PPOs are their higher costs for deductibles and the tendency for the insured to have to pay much higher fees for out-of-network doctor’s visits. This cost is sometimes offset by the fact that many enrollees do not have to switch doctors if they would like to join a PPO. So if you have a doctor you like, it may be worth considering enrolling in this plan. This is another example where doing your homework can pay off!
Some examples of PPOs include:
1. NPPN
2. Cigna PPO
3. Broadspire
To learn more about PPOs visit:
POS
A Point of Service plan has similarities to both HMOs and PPOs. In this plan, the insured chooses a primary caregiver where all medical consultation will begin. This doctor will authorize referral to a specialist when needed.
This system, while effective, can lead to problems for the patient if they choose to see a specialist that is not recommended to them by their primary caregiver. Why? Because the insurance company may choose not to cover the specialist’s services! This can be a costly mistake. With a Point of Service, all care first gets filtered through this primary caregiver.
While there are quite a few possibilities when it comes to choosing a POS plan, the best example is when a family has a certain doctor that they trust and really like. This doctor will make all reference point to any other caregiver when a special need arises. Of course the “perfect doctor” is not always available, but this plan can work well when you have a caregiver that you trust.
To learn more about Point of Service Plans:
Traditional Health Insurance
Also known as a “Fee for Service Plan”, this is a form of health care where insurance companies pay for a percentage of the care received by a patient. Many services are limited or not covered at all under such plans, and you need to fill out forms and send them to your insurer to receive payment for fee-for-service claims.
It is, however possible to see just about any doctor without the need for referrals. You aren’t limited to certain networks of caregivers or physicians. Basically under a traditional health plan there is a lot more freedom for the enrollee to make any medical decisions they may need completely on their own. Many people swear by Fee for Service plans for these reasons alone.
Major Medical
Major Medical does not fall under the category of managed care. Here, the insured party is responsible for paying a portion of the deductible before insurance pays any benefits. If the enrollee needs insulin for diabetes, they would pay a percentage of the cost of the insulin (perhaps 20%) and the insurance would take care of the rest.
Here, the insured may request to see any doctor or clinic to receive treatment and then pay the provider directly while later requesting a reimbursement by the insurance company. There is some flexibility here – the patient may choose to be reimbursed after care or “up front”, which occurs when the patient signs a release allowing the insurance company to pay the health care provider directly. Then, the patient pays the remaining deductible or percentage.
This system has been around for a long time in the United States.
For more on the topic of various types of healthcare, visit:
[...] Lazear Editors Note: The following is Part II of a two-part guide to American health care. Click here to see yesterday’s post on the various types of health insurance. Today’s we highlight [...]
Bravo! A genuine service to the debate. Thank you!
Fajna stronka, bede tu wpadal czesciej, pozdro
[...] resources. Also, checkout our two part Guide to American Health Care, which we posted this week, here and [...]
[...] Know Your Options: A Guide to American Health Care Part I [...]