Health Insurance Matrix
University of Phoenix Material
Health Insurance Matrix
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.
Indemnity
In 1932 the American Medical Association (AMA) adopted a strong position against prepaid group practices, favoring instead indemnity-type insurance that protects the policyholder from expenses by reimbursement (Jones & Bartlett, 2007). As one of the first health policies in the U.S., indemnity plans are considered traditional health plans.
Indemnity insurance plans have three options. Two of them are reimbursement plans (Howell, R., 2014). One typically covers 80 percent while the patient covers 20. The other option covers 100 percent. The third option pays the insured a certain amount each day for a maximum number of days. Indemnity plans are fee-for-service plans (retrospective).
With an indemnity plan the patient pays for care. Afterwards the patient must submit a claim in order to be reimbursed.
Indemnity plans are non-network based plans with open-access. This gives insured individuals \ flexibility when choosing doctors, hospitals, and health care facilities. No primary care physician (PCP) is necessary. No referrals are needed.
Indemnity plans provide patients with flexibility and control over their medical care. No PCP must be selected. No referrals are needed to obtain services. The drawback however, is that patients must submit claims in order to receive reimbursement for services. This can take time. Indemnity plans only reimburse services covered by the insurer. Services not covered will require full payment from the patient.
Providers can require the costs for services up front to guarantee they are getting what they
Health Insurance Matrix
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.
Indemnity
In 1932 the American Medical Association (AMA) adopted a strong position against prepaid group practices, favoring instead indemnity-type insurance that protects the policyholder from expenses by reimbursement (Jones & Bartlett, 2007). As one of the first health policies in the U.S., indemnity plans are considered traditional health plans.
Indemnity insurance plans have three options. Two of them are reimbursement plans (Howell, R., 2014). One typically covers 80 percent while the patient covers 20. The other option covers 100 percent. The third option pays the insured a certain amount each day for a maximum number of days. Indemnity plans are fee-for-service plans (retrospective).
With an indemnity plan the patient pays for care. Afterwards the patient must submit a claim in order to be reimbursed.
Indemnity plans are non-network based plans with open-access. This gives insured individuals \ flexibility when choosing doctors, hospitals, and health care facilities. No primary care physician (PCP) is necessary. No referrals are needed.
Indemnity plans provide patients with flexibility and control over their medical care. No PCP must be selected. No referrals are needed to obtain services. The drawback however, is that patients must submit claims in order to receive reimbursement for services. This can take time. Indemnity plans only reimburse services covered by the insurer. Services not covered will require full payment from the patient.
Providers can require the costs for services up front to guarantee they are getting what they
References: Austin, A. & Wetle. V. (2012) The United States Health Care System, Combining Business, Health, and Delivery. (2nd ed.) Upper Saddle River, NJ: Pearson Education Barsukiewicz, C.K., Raffel, M.W., & Raffel, N Stevens, S. (2005). Pros and Cons of Health Savings Accounts. Retrieved from http://www.forbes.com/feeds/mstar/2004/04/08/mstar1_11_14978_132.html Kiplinger Gutske, C. (2013) Pros and Cons of Health Insurance POS Plans. Retrieved from http://www.bankrate.com/finance/insurance/pros-cons-health- insurance-pos-plans.aspx Jones & Bartlett Publishers Howell, R. (2014) Indemnity Health Insurance Definition. Retrieved from http://www.ehow.com/about_7290655_indemnity-health-insurance- definition.html