The Private Health Insurance MarketA. Health CoverageHealth coverage for individuals in the U.S. can be categorized into four major segments: employer-based, public, private non-group (individual coverage), and uninsured. Employer- based coverage is health insurance funded through employers and is the largest health insurance market. The public system is made up of government programs, including Medicare, Medicaid, the military system, and other federal, state and local programs. The smallest segment of the market is those who contract on an individual basis with health plans and insurers. The final group is those who have no health insurance coverage. The following statistics show the breakdown of the private market (excluding elderly beneficiaries). Although not included here, Medicare covers approximately 40 million lives. (All of the information mentioned in this article is based upon the health insurance market before the enactment of the Patient Protection and Affordable Care Act of 2010.) Show
Heath Insurance Enrollment B. Employer-based CoveragePrivate employer-based health coverage is provided by two different types of employer-sponsored health plans: fully insured plans and self-funded plans. 1. Fully Insured
Health Plans: a. Commercial health insurers. Commercial health insurers (sometimes called indemnity insurers) are generally organized as stock companies (owned by stockholders) or as mutual insurance companies (owned by their policyholders). A prominent example is Aetna. b. Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield (BCBS) plans cover approximately 90 million individuals. Historically, most of these plans were organized as not-for-profit organizations under special state laws by state hospital (Blue Cross) and state medical (Blue Shield) associations. These laws differed significantly across states, sometimes imposing special obligations or regulatory requirements on BCBS plans and sometimes providing financial advantages such as favorable tax status. Most of the BCBS plans now offer managed care plans, such as HMO and PPO plans, as well as traditional insurance plans. In recent years, several of the state BCBS plans have reorganized themselves as for-profit organizations and now operate like commercial insurers. c. Health Maintenance Organizations (HMOs). HMOs cover approximately 70 million people. HMOs usually are licensed under special state laws that recognize that they tightly integrate health insurance with the provision of health care. HMOs operate as insurers and as health care providers. In many states, HMO regulation is shared by agencies that oversee insurance and agencies that oversee heath care providers. Examples of state licensed HMOs include Kaiser Permanente and Harvard Pilgrim. 2. Self-Funded Employee Health Benefit Plans C. Types of Managed CareIn today’s insurance market, approximately two-thirds of the insured population has health coverage with elements of managed care. 1. Managed Care Organizations a. Health Maintenance Organization (HMO): (see prior definition). With HMOs, providers are paid only if they have contracted with the plans and have received a referral from a primary care physician. b. Preferred Provider Organization (PPO): PPOs are fee-for-service health plans that contracts with providers of medical care to provide services at discounted fees to enrollees. Providers are paid more if they have contracted with the plans, but are also covered at a lesser payment rate if they have not contracted with the plans. c. Point-Of-Service (POS): These plans are a hybrid of HMO and PPO elements. Providers are paid more if they have contracted with the plans and also are paid more if they have received a referral from a primary care physician. 2. Managed Behavioral Health Care Organizations (MBHOs or Carve-Outs) D. Consumer-Directed Health Plan (CDHP):A CDHP combines a high-deductible health plan with a tax-advantaged account, normally either a health reimbursement account (HRA) or a health savings account (HSA), which enrollees can use to pay some of their medical expenses. Withdrawals from HRAs and HSAs to pay for qualified medical expenses are exempt from federal income taxes. Any unused funds in an HRA or HAS can be rolled over for future use. HRAs are established and owned by employers to reimburse employees for certain medical expenses that enrollees incur prior to meeting a health plan’s high deductible. By contrast, HSAs are owned by employees. State Job ClassificationState governments are a major employer of mental health professionals. In general, a state job classification for MFTs must be created before state agencies can hire MFTs to serve as MFTs within state government. The following fact sheet developed by AAMFT provides a brief overview on how state job classifications are created, as well as information on current state job classifications for MFTs. What is the main type of healthcare system in the United States?Rather than operating a national health service, a single-payer national health insurance system, or a multi-payer universal health insurance fund, the U.S. health care system can best be described as a hybrid system.
Which of the following is the most common type of hospital in the United States?Most common hospital types in the U.S.. Which of the following organizations has the overall responsibility for food safety regulation in the United States?U.S. Food and Drug Administration (FDA)
The FDA is charged with protecting consumers against impure, unsafe, and fraudulently labeled products. FDA, through its Center for Food Safety and Applied Nutrition (CFSAN), regulates foods other than the meat, poultry, and egg products regulated by FSIS.
Which of the following is a federal agency that is the world's largest source of biomedical research funding group of answer choices?NIH is the largest public funder of biomedical research in the world, investing more than $30 billion in taxpayer dollars to achieve its mission to enhance health, lengthen life, and reduce illness and disability.
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