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1、 Trieschmann,Hoyt&Sommer/多广AiiXionLossofHealthRiSkChapter17ManagementANDINSURANCE皇ChapterObjectives*Describethesimilaritiesanddifferencesamongcommercialinsurers,traditionalBlueCrossandBlueShieldassociations,andthenewfor-profitBluesorganizations*Explainthemajorcharacteristicsofhealthmaintenanceorgani
2、zationsandexplainhowpoint-ofserviceplansandpreferredproviderorganizationsdifferfromthem*ComputetheamountofthecoveredlossthatwouldbereimbursablefromaninsurerGiventheamountofthelossandapplicabledeductibles,coinsurancepro)isi)nsandlimits。Distinguishamongformsofbasichealthinsurancepoliciesanddescrlbesth
3、reeformsofmajormedicalInsuranceChapterObjectivesListseveralcharacteristicstoconsiderwhenpurchasinglong-termcareanddisabilityincomeinsurancecontracts*ExplainthenatureandstructureofMedicarebenefitsandtheapproachusedtostandardizeMedigappolicies*Explainthemandatoryandallowableprovisionsinindividualhealt
4、hinsurancewithrespecttograceperiods,reinstatement,claimprocedures,occupationalissues,misstatementofagewhenapplyingforcoverage,andtheexistenceofmorethanonepolicycoveringthesameloss*DescribehealthcarereformsrecentlyenactedorcurrentlyunderconsiderationintheUnitedStatesIntroduction*Thehighcostofhealthca
5、re,combinedwithconcernsaboutthelackofavailabilityofhealthinsuranceforsomepersons-HasledtoarapidlychangingenvironmentinwhichhealthcareisdeliveredintheUnitedStatesalthInsuranceProviders*Healthinsuranceisprovidedbyseveraltypesoforganizations=Commercialinsurers=BlueCrossandBlueShieldassociationsHealthma
6、intenanceorganizations(HMOsJPointofservice(POS)plansPreferredproviderorganizations(PPOs)*Whenpaymentforhealthexpensesisprovidedasanemployeebenefit一Manyemployerssetupselfinsurancearrangementstoeitherreplaceorsupplementcoverageobtainedfromoneormoreofthesetypesofproviders。Somehealthinsuranceisprovidedb
7、ytheMedicareandMedicaidsystems一SocialinsurancearrangementssetupthroughthefederalandstategovemmentsInsurersandtheBlues*Untilrecently,commercialinsurersandBlueCrossandBlueShield(theBlues)associationswerelegallyverydifferentintermsofstructureThoughfromtheperspectiveofanindividualinsuredtheyappearedtobe
8、VerySimilar。TheBlueswereoriginallydesignedtobenonprofitorganizationsAllowingtheirsubscriberstoprepaysometypesofhealthcareeXpenSes*BlueCrossassociationsfocusedontheprepaymentofhospitalexpenses*BlueShieldgroupscoveredphysiciansservices*Whencombined,medicalexpensecoverageofferedbytheBluescanbevirtually
9、identicaltothatavailablefromcommercialinsurersInsurersandtheBlues。Beginninginthemid-1990sthestructuraldifferencesbetweentheBluesandinsurersbeganeroding=Inanefforttobecomemorecompetitive,Bluesinseveralstatesbeganformingoracquiiringfor-profitsubsidiariesAnumberoftheBluesorganizationsconvertedtoafor-pr
10、offtstatusintheirentirety。TheBlueswereindependentgroupsorganizedbydoctors,hospitals,andothermedicalserviceprovidersinaparticulargeographicregionTheyagreedtomeetcertaincommonstandardsinexchangeforauthorizationtousetheBluesname一ManystatesgrantedtheBluespreferentialtaxtreatmentbecauseoftheirnonproftsta
11、tusInsurersandtheBluesAschangesinthehealthcaredeliverysystemevolved-ManyBluesfoundthemselvesinsuringalargepercentageofindividualswhohaddifficultyobtaininghealthinsuranceelsewhere-CausedtheBluestoexperiencesubstantialfinanciallosses。Additionally,traditionalnot-for-profitBlueshavemorelimitedaccesstoca
12、pitalthanfor-profitstockcompaniesHealthMaintenanceeQrganizationes(HMOs)*Bythebeginningofthe21stcentury,morethan80milionpersonsIntheU.S.wereenfolledinHMOs。Allaredesignedtoprovidetheirmemberscomprehensivehealthserviceswithinawell-definedgeographicalarea。TheHMOispaidasetfeepermonthbyitsmembers一Anditpro
13、videsallnecessarymedicalservices。CoverageisusuallybroaderthanthatprovidedbyinsurersBothcostcontrolandpreventionofhealthproblemstendtobeemphasized。Bystressingregularhealthcare,earlydiagnosisandtreatment,anddiseaseprevention一HMOscanbeeffectiveinhelpingthemembersidentifyandcorrectsmallhealthproblemsbef
14、oretheybecomemaoronesHealthMaintenanceeQrganizationes(HMOs)*PersonsbelongingtoanHMOgenerallymustreceiveallmedicalcarefromphysiciansassociatedwiththatHMO。昌艮矛葛personchoosesaprimarycarephysicianwithintheThisdoctorisresponsibleforcoordinatingallmedicalcareforthepatient,IncludingaccesstomedicalspecialistsPrimarycarephysiciansaresometimesreferredtoasgatekeepers。MostmedicalspecialtiesarerepresentedwithintheHMOButifhighlyspecializedtreatmentisrequiredpatientscanbereferredtootherdoctorsatnoadditionalcosttothepatient。Arrangementsalsoexistwithhospitalsintheareafortheprovisionofhospitalserviceswhenneeded
