Trieschmann,Hoyt&Sommer/多广AiiXionLossofHealthRiSkChapter17ManagementANDINSURANCE皇ChapterObjectives*Describethesimilaritiesanddifferencesamongcommercialinsurers,traditionalBlueCrossandBlueShieldassociations,andthenewfor-profitBluesorganizations*Explainthemajorcharacteristicsofhealthmaintenanceorganizationsandexplainhowpoint-ofserviceplansandpreferredproviderorganizationsdifferfromthem*ComputetheamountofthecoveredlossthatwouldbereimbursablefromaninsurerGiventheamountofthelossandapplicabledeductibles,coinsurancepro)isi)nsandlimits。DistinguishamongformsofbasichealthinsurancepoliciesanddescrlbesthreeformsofmajormedicalInsuranceChapterObjectivesListseveralcharacteristicstoconsiderwhenpurchasinglong-termcareanddisabilityincomeinsurancecontracts*ExplainthenatureandstructureofMedicarebenefitsandtheapproachusedtostandardizeMedigappolicies*Explainthemandatoryandallowableprovisionsinindividualhealthinsurancewithrespecttograceperiods,reinstatement,claimprocedures,occupationalissues,misstatementofagewhenapplyingforcoverage,andtheexistenceofmorethanonepolicycoveringthesameloss*DescribehealthcarereformsrecentlyenactedorcurrentlyunderconsiderationintheUnitedStatesIntroduction*Thehighcostofhealthcare,combinedwithconcernsaboutthelackofavailabilityofhealthinsuranceforsomepersons-HasledtoarapidlychangingenvironmentinwhichhealthcareisdeliveredintheUnitedStatesalthInsuranceProviders*Healthinsuranceisprovidedbyseveraltypesoforganizations=Commercialinsurers=BlueCrossandBlueShieldassociationsHealthmaintenanceorganizations(HMOsJPointofservice(POS)plansPreferredproviderorganizations(PPOs)*Whenpaymentforhealthexpensesisprovidedasanemployeebenefit一Manyemployerssetupselfinsurancearrangementstoeitherreplaceorsupplementcoverageobtainedfromoneormoreofthesetypesofproviders。SomehealthinsuranceisprovidedbytheMedicareandMedicaidsystems一SocialinsurancearrangementssetupthroughthefederalandstategovemmentsInsurersandtheBlues*Untilrecently,commercialinsurersandBlueCrossandBlueShield(theBlues)associationswerelegallyverydifferentintermsofstructureThoughfromtheperspectiveofanindividualinsuredtheyappearedtobeVerySimilar。TheBlueswereoriginallydesignedtobenonprofitorganizationsAllowingtheirsubscriberstoprepaysometypesofhealthcareeXpenSes*BlueCrossassociationsfocusedontheprepaymentofhospitalexpenses*BlueShieldgroupscoveredphysiciansservices*Whencombined,medicalexpensecoverageofferedbytheBluescanbevirtuallyidenticaltothatavailablefromcommercialinsurersInsurersandtheBlues。Beginninginthemid-1990sthestructuraldifferencesbetweentheBluesandinsurersbeganeroding=Inanefforttobecomemorecompetitive,Bluesinseveralstatesbeganformingoracquiiringfor-profitsubsidiariesAnumberoftheBluesorganizationsconvertedtoafor-profftstatusintheirentirety。TheBlueswereindependentgroupsorganizedbydoctors,hospitals,andothermedicalserviceprovidersinaparticulargeographicregionTheyagreedtomeetcertaincommonstandardsinexchangeforauthorizationtousetheBluesname一ManystatesgrantedtheBluespreferentialtaxtreatmentbecauseoftheirnonproftstatusInsurersandtheBluesAschangesinthehealthcaredeliverysystemevolved-ManyBluesfoundthemselvesinsuringalargepercentageofindividualswhohaddifficultyobtaininghealthinsuranceelsewhere-CausedtheBluestoexperiencesubstantialfinanciallosses。Additionally,traditionalnot-for-profitBlueshavemorelimitedaccesstocapitalthanfor-profitstockcompaniesHealthMaintenanceeQrganizationes(HMOs)*Bythebeginningofthe21stcentury,morethan80milionpersonsIntheU.S.wereenfolledinHMOs。Allaredesignedtoprovidetheirmemberscomprehensivehealthserviceswithinawell-definedgeographicalarea。TheHMOispaidasetfeepermonthbyitsmembers一Anditprovidesallnecessarymedicalservices。CoverageisusuallybroaderthanthatprovidedbyinsurersBothcostcontrolandpreventionofhealthproblemstendtobeemphasized。Bystressingregularhealthcare,earlydiagnosisandtreatment,anddiseaseprevention一HMOscanbeeffectiveinhelpingthemembersidentifyandcorrectsmallhealthproblemsbeforetheybecomemaoronesHealthMaintenanceeQrganizationes(HMOs)*PersonsbelongingtoanHMOgenerallymustreceiveallmedicalcarefromphysiciansassociatedwiththatHMO。昌艮矛葛personchoosesaprimarycarephysicianwithintheThisdoctorisresponsibleforcoordinatingallmedicalcareforthepatient,IncludingaccesstomedicalspecialistsPrimarycarephysiciansaresometimesreferredtoasgatekeepers。MostmedicalspecialtiesarerepresentedwithintheHMOButifhighlyspecializedtreatmentisrequiredpatientscanbereferredtootherdoctorsatnoadditionalcosttothepatient。Arrangementsalsoexistwithhospitalsintheareafortheprovisionofhospitalserviceswhenneeded