The Type of Health Insurance Coverage I Currently Have, Term Paper Example

My health insurance was traditionally referenced to as a health plan because it is a HMO. They are also known as subscription-based medical care due to their attachment to HMOs, preferred provider organizations (PPO), or simply point of service plans. When considering the similarity of function in relation to other pans in the market place my plan is comparable to pre-paid dental, pre-paid legal and pre-paid vision plans (O’Hare, 2000).

This is so because the aim is to pay for a specified number of services. For example, I am allotted $500 for prophylactic treatment such as vaccinations, 400 days of hospice or skilled nursing facility care, 50 home health visits, 20 spinal manipulation charges, $1,000 for medication each month. The number of services that are listed is extensive. This plan includes dental and vision with out-of-pocket co-payments once it exceeds the allocation celling (O’Hare, 2000).

Health Maintenance Organization (HMO) Act of 1973 enforced the law that once an organization has 25 or more employees they must cater for their employees’ health needs through some type of assistance. These are the circumstances under which my subscription health plan emerged. Even though this might not be the best insurance coverage it does help greatly in the overall health care costs when doctor visits have to be made. A utilization review is often conducted by a managed care nurse who describes the service eligibility of each subscriber within in the subscription health plan protocol (Dorsey, 1975).

HMOs do not function like traditional indemnity insurance. Only doctors who have registered to be participants of the program are listed as providers. Providers in every category must comply with HMO regulations to begin and maintain eligibility to participate in the programs. Each subscriber must select a primary care physician, who acts as a gate keeper in accessing other medical services. They could be general practitioners, pediatricians or interns. In order to see a specialist the subscriber must receive a referral from the primary care physician. Specialists must be participating provider within the HMO group (Dorsey, 1975).

A marked advantage of being a subscriber in a HMO lies in receiving significant co-payment reduction in preventative care which comparable plans do not offer. The goal is to encourage frequent doctors’ visits and primary health promotion strategies, which will ultimately limit secondary health care interventions. Hence, notable limitations are high cost for outpatient mental health services and experimental treatments. However, emergency care is covered irrespective of the provider or participating hospital.

Explain the process of seeking healthcare under yourHealth plan for the following scenarios:

Annual physical examination:-

Annual physical screening is part of the preventive mechanism within the HMO subscription plan and Health Living Requirement of 2013. It encompasses a series of diagnostic testing. The process begins by calling to make an appointment for a scheduled visit to the primary care physician. If my provider conducted an annual physical before October 12^th

2012 I will have to obtain the annual physical results for that period and have him fill it out on the Annual Physical Screening Form explaining those results (Kongstvedt, 2001).

The next step is going to get laboratory workup. When the results are obtained I would have to schedule another appointment with my primary care physician to discuss any abnormalities and plan for further interventions. At the same time this data is transmitted to the Annual Physical Screening Form electronically for the current period. If results are within the healthy range my primary care physician will then initials these vitals as normal. They include blood pressure, blood sugar; cholesterol levels; weight and tobacco consumption levels. This data is stored as reference the next year. This process covers a physical examination required by an employer. After these initial investigation often accompanied by a tuberculin test forms are mailed to the agencies mandating the physical examination.

Based on laboratory evaluation results my primary care may follow through with diagnostic screenings such as mammogram; colonoscopy; pap smear; vision, hearing, liver function tests; barium meal and as many which may be necessary in ruling our any suspected dysfunction in blood analysis. Once these tests return negative my annual physical report is considered healthy.

Seeing a specialist:-

For me to see a specialist using my health care HMO plan I must be referred by my primary care physician. The way health care in America is designed no specialist will see a patient without being referred through the gate way system of physician referral program. Also, the only way I will be referred to a specialist is if my annual physical report retuned with some suspicions findings, which my primary care will need a specialists to verify. My primary care diagnosed some gastric dysfunction and referred me to a gastro intestinal specialist.

Prior to seeing the specialist I had to receive approval from my HMO regarding the necessity for this intervention. I had to engage in a utilization review process conducted by a managed care nurse who evaluated me with regards to my coverage for that procedure. Approval came within a five days and I was scheduled for a visit. There was a waiting list and I could not have been seen sooner than one month. My case was not considered an emergency so I waited to see the specialist since there were no serve symptoms.

Admission to the hospital for elective surgery:-

After being seen by the specialist I was diagnosed with a condition requiring elective surgery. My HMO pays 100% for this procedure, but a pre-certification process precedes it. It begins by first calling the number at the back of my member card and inquiring about my eligibility for the procedure, which must be deemed extremely necessary within the framework of a utilization review process conducted by a managed care nurse. During this time I have to identify a surgeon within the net-work who is contracted to conduct a surgery of this nature.

Pre-certification also embodies gaining approval from my HMO by receiving a code through which the surgeon will be paid for the services rendered. My hospitalization period has to be pre-certified as well and the hospital too. After, the code has been assigned a managed care nurse from my HMO will again review the surgeon’s orders to verify that associating treatment are necessary. Then I proceed to be admitted to an institution within the network providing such services. A $15 co-pay is required for each visit to the surgeon’s office.

 References.

Dorsey, L. (1975). The Health Maintenance Organization Act of 1973(P.L. 93-222) and Prepaid Group Practice Plan, Medical Care, 13 (1), 17-22

Kongstvedt, P. (2001). The Managed Health Care Handbook, (4th edition). Aspen Publishers, Inc

O’Hare, T. (2000). Individual Medical Expense Insurance. The American College.