Health Maintenance Organizations (HMO)

The number of Health Maintenance Organizations (HMOs) is growing by leaps and bounds and is in direct correlation with increasing health care costs.
The purpose of HMOs is to manage health care by using a prepaid model that emphasizes early treatment and prevention. This prepayment is referred to as a service-incurred basis and is paid by the consumer.
This emphasis on prevention such as routine physicals, diagnostic screening is paid for in advance. The model is a direct contrast to health insurance plans that historically did not pay for preventive programs but only paid after the fact for injury and illness.
In theory, the HMOs focus on prevention is ultimately supposed to reduce health care costs. At the same time, HMOs provide medical treatment, hospital and surgical when needed.
There is another way that HMOs differ from the traditional health insurance providers. HMOs have two step system that is not shared by insurance companies. Under the traditional method, consumers receive the health care itself from the medical profession and the financial coverage from the insurance company.
In sharp contrast, the HMO provides both the health care services AND the health care coverage.
These are combined because the HMO is made up of medical practitioners who provide specific services to HMO members at prices that are pre-set and the HMO member agrees to pay the HMO a specified amount in advance to cover necessary services. Therefore, the HMO is furnishing health services as well as making the financial arrangements.

As we have stated, the emphasis on prevention and the effort to containing cost is the major factor for developing HMOs. However, federal law also encourages the development of HMOS. They may receive government grants as well as requiring certain employers who offer health benefits, to offer HMO enrollment as an option by meeting certain criteria.
The basic structure of HMOs includes contractual agreements with a variety of facilities and health care providers to provide services to HMO subscribers. Within this structure are four different types, Group, Staff, Network and Individual Practice Association.
Group model – Early on this was the predominant scenario. With this arrangement the HMO contracts with an independent medical group that specializes in a variety of medical services and the HMO in turn provides these services to members. Additionally, the HMO is paying another entity as a whole rather than individuals.
Staff model – This arrangement is pretty self-explanatory
wherein the physicians are paid employees working on the staff of an HMO in a clinical setting at the HMO physical facilities. The HMO often owns the hospital as well. In this model the HMO is taking all the financial risk as opposed to the group model.
Network model – This arrangement works like the Group model with the difference being that the HMO will contract with more than one group to provide the services. The primary purpose for this model is to provide convenience and increase accessibility for the members.
Individual Practice Association Model – This structure is designed to give maximum flexibility to the HMO members wherein they contract individually for all services. There are no separate HMO facilities and all services operate out of their own facilities.

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Blue Cross/Blue Shield

These service organizations represent producers cooperatives. Hospitals and physicians who sponsor Blue Cross/Blue Shield plans are providing the insurance, therefore they are considered to be the producers of the cooperative.
Originally Blue Cross and Blue shield were separate voluntary and tax-exempt associations. Blue Cross provided payments to hospitals and Blue Shield covered physicians, medical and surgical fees. People originally covered under these plans were traditionally known as subscribers since Blue Cross and Blue shield differ from traditional insurance companies.

In most states, the two have merged, but each group still covers the expenses for which they were initially created. Over the years the tax advantages they originally enjoyed have deteriorated and many states have removed their exempt status. Additionally the federal Tax Reform Act of 1986 now makes them taxable as insurance companies.

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Traditional Insurers

This type of company is one that has evolved over time into a ‘branded” image in the eyes of the public. This is the opposite of what we have come to know in today’s world as Health Maintenance (HMO) and Preferred Provider Organizations (PPO).
A traditional insurer selling health coverage may specialize in just health coverage. The types of insurance they sell may be referred to as accident and health (A&H) or accident and sickness (A&S) companies. Most states require a separate license to write life, health and property casualty.
Stock and Mutual. Not only can an insurance company be
categorized by the type of insurance, they can also be considered in terms of its ownership as either a stock or mutual company.
At the time of organization, a stock company sells stock to raise the money necessary to operate a business. The stockholders are not necessarily insured by the company nor do policyholders necessarily own stock in the company. It is in business solely for the purpose of selling insurance to policyholders.
On the other hand, with a mutual company the policyholders are also owners of the company and as such, can vote to elect the company management. Any monies beyond the operating costs of the company may be returned to the policyholders as dividends or reductions in future premiums.
Consumer Cooperatives. There are two different types of cooperatives. They are consumer cooperatives and producer cooperatives. Producer cooperatives include companies like Blue Cross/Blue shield and some Health Maintenance Organizations which we will discuss further on.
Additionally, there are two types of consumer cooperatives. One is the mutual insurance model discussed previously and the other less common and unincorporated type is a reciprocal company.
A reciprocal company is based on the model of give and take. Members agree to share insurance responsibilities among all members.
All members insure one another and share in the losses and no member can buy insurance without committing to providing insurance in return. This type of consumer cooperative is managed by an attorney-in-fact who handles all matters of business for the cooperative.
Participating and Non-participating Policies. These terms indicate that the policyholder of a traditional type of insurance, either does or does not participate in, or receive, a share of any surplus that results from an insurers business operations. These terms are also known as par and non-par.
The surplus from which participating policyholders might receive a return are excess reserves for claims, interest on investments and savings on expenses. This represents amounts not ear marked for any particular purpose and are therefore available to participating policy owners.
Domestic, Foreign and Alien Companies
Here in the United States, companies are usually organized and chartered under the laws of one particular state and it is common for them to do business in many states. A company that operates its home office in the state where it is organized is known in that state as a domestic company. In any other states where they do business the
company is considered a foreign company. If the home office of a company is located outside the United States, it is considered an alien company. No matter whether it is domestic, foreign or alien a company must be registered in every state in which they operate.

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MEDICAL INSURANCE

If you recall, we explained that there are two broad categories of health insurance policies: disability and medical expense. Thus far we have covered disability. Now we’ll take a look at basic medical expense insurance.
Basic medical expense policies provide for medical expenses that result from accidents and sickness. This is a loose term that refers to various medical, hospital and surgical benefits.
The broad category of medical expense coverage provides a wide range of benefits for hospital, surgical and medical care. Other benefits may apply as well, such as private nurses, convalescent care, and more.
Policies may be written as such that they may be limited to only
one or two types of coverage like hospital or miscellaneous medical costs or surgical expenses. These are known as basic plans.
Other, more broadly written, policies may cover all expenses resulting from accident or illness using some specific exceptions.
Medical plans include fee-for-service wherein doctors and other providers receive a payment that does not exceed their billed charge for service provided.
Prepaid plans provide medical or hospital benefits in the form of service rather than dollars. Many things need to be considered when selecting a medical expense plan such as:
Specified coverage versus comprehensive care. In other words does the plan feature only specific benefits or is the coverage comprehensive?
Any provider versus a limited number of providers. Are you required to choose from a specific list of providers?
National versus regional operation. Is the plan limited to a specific geographical region or operate nationwide?
Insured versus subscribers. Are participants considered insureds (the person who receives the benefit) or subscribers (the person who is paying the premium)?
We are going to take a look at the limited coverage for hospital, medical and surgical expenses. Discussing this separately first, will
help you to understand how the components are combined in major medical and comprehensive policies.

The broad definition of basic medical expense insurance in most states includes hospital, medical and surgical expenses. The purpose of this type of insurance is to cover a broad range of medical, hospital and surgical expenses as well as separate categories of medical expenses.
Let’s explore individual versus group coverage.
No matter how a policy is written, narrowly or broadly, medical expense insurance is designed to reimburse for the cost of care whether it results from injury or illness.
Both individual and group policies are available to consumers. Normally individual policies are more costly along with having limited benefits but generally speaking, both types cover the same medical services.
Hospital expense benefits provide for expenses incurred during hospitalization. Indemnities usually fall under two broad groups:

• Room and board – including nursing care and special dietary requirements

• Miscellaneous medical expenses – including x-rays, lab work, medications, medical supplies and operating and special treatment rooms

In some cases, benefits might be included for certain surgeries and related costs like pain killers given during a hospital stay.
Room and board benefits may be paid based on indemnity or reimbursement depending upon the particular policy. When paid on an indemnity basis, the insurer pays a specified rate per day that has been pre-determined and is laid out in a schedule within the policy.
The schedule will spell out the details of the benefit coverage as it pertains to length of stay. Once the length of stay has been exhausted, no more benefits are available. These are sometimes called dollar amount plans and typically the number of days is from 90 up to 365.
More commonly used is a reimbursement basis, also known as an expenses-incurred basis. With this type of coverage the policy will pay in one of two ways – the actual charges for a semi-private room or a percentage of the actual charges. There are no specific dollar amounts but a maximum number of days will still be specified.
Surgical Expense Benefits fall under two plans, scheduled and non-scheduled.
In the scheduled plan, surgical expense policies pay the fees incurred from the surgeons services and related costs incurred when the insured has an operation. Typical related costs include fees for an assistant surgeon, anesthesiologist and can even include the operating
room when it is not covered as a miscellaneous item.
Basic surgical coverage can be included in the same policy as basic hospital and medical expense and are normally included in a schedule listing major commonly performed operations and the benefits payable for each.
This gets a bit tricky and you need to be aware of how the insurance company determines the benefit. Just because a specific surgery is not listed in the schedule does not necessarily mean that there is no benefit for it available. It might mean that the insurer indemnifies that surgery based on absolute value and the relative value of each procedure.
In other words, let’s say that the insurer determines that a certain surgical procedure has a prevailing value of $1500 and indicates that in the schedule included in your policy. That is considered the absolute value. Now, let’s say that there is another procedure not listed in the schedule that is say 50% less complicated as the $1500 procedure. In this case, the relative value would be $750 and that is the benefit amount that will be paid for the less complicated procedure.
Using a non-scheduled scenario, when surgical benefits are not listed by a specific dollar amount in a schedule, the policy will pay based on what is considered usual, customary and reasonable in a
certain geographical area and is also known as UCR.
This non-scheduled type of indemnity is found most often in major medical and comprehensive policies which we will discuss further along.
As you might imagine, under this type of arrangement the UCR is determined by the amount that physicians in the local area usually charge for the same procedure.
Regular medical expense benefit is another category that is sometimes known as physician’s non-surgical expense. This coverage is for non-surgical services a physician provides and can sometimes be narrowly applied to physician visits while the patient is in the hospital.
If this is the case the benefit will most likely pay for a specified maximum number of visits per day, a specified maximum dollar amount per visit and a specified number of days coverage applies.
In other policies this benefit could be for non-surgical services performed by a physician whether the patient is in or out of the hospital. Once again there are limits such as $100 per visit up to 50 visits per year depending on the policy.
Other medical expense benefits fall into a category in addition to the hospital, surgical and medical benefits previously discussed. These optional benefits vary from insurer to insurer and may or may not include as part of their standard policies. Separate policies can
sometimes be written to include these benefits. Some of them are:

• Maternity

• Convalescent – Nursing home
• Emergency first-aid
• Home health care
• Mental infirmity

• Hospice care
• Prescription drugs
• Dread disease
• Outpatient treatment
• Dental
• Private duty nursing
• Vision

We will not cover all of these options, but will let’s take a look at the most common.
Maternity benefits are sometimes included in policies subject to certain conditions and limitations. The most usual limitation is a 10 month waiting period designed to prevent the purchase of health insurance just to cover pregnancy and childbirth expenses. Interesting to note, however, group policies for employee groups of 15 or more are required by law to provide maternity benefits on the same basis as non-maternity benefits. This means that in a case such as this, the
waiting period would not apply unless non-maternity benefits also required a 10 month waiting period.
Aside from the group scenario above, many policies just exclude maternity benefits totally but make them available at extra cost. Where maternity benefits do apply, the benefit usually includes newborn care while the mother is in the hospital.
Other benefits that are sometimes available under the same maternity coverage might include cesarean deliveries, natural abortions and elective abortions.
Emergency First Aid Coverage applies to an accident that may call for immediate first-aid on the scene. This applies when a medical professional who just happens on the scene provides first-aid service he/she might bill the insured. Sometimes treatment like this must be performed without the knowledge or assent of the insured. Some policies offer coverage for such contingencies and normally must incur within a very short time after an accident.
Mental Infirmity historically has been excluded from most policies. However, in recent years more and more policies include this type of coverage but with limitations. The benefits are usually much lower than physical ailments and a stated percentage of the benefit paid for other types of medical care is included.

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DISABILITY INCOME INSURANCE

When a person becomes disabled and unable to work, at some point their income will stop. It might be sooner or later, but unfortunately, life goes on and daily living expenses continue to mount.
Disability income insurance is available to continue at least a portion of ones income while unable to work. It’s sad, but most people give more attention to life insurance than they do about income replacement should they become disabled.
Disability income insurance is available individually or sometimes as a portion of a group benefit provided by an employer in their group package.
Individual policies are most often sold to self-employed and
professional people. The amount of the benefit relates to earnings and is matched as close to after tax income as possible. Generally it is up to 60% of monthly net income and there is usually a cap on the amount.
When included as part of a employee group benefit package, disability income policies are usually more liberal than individual plans as far as limitations and exclusions. It is also much easier to acquire coverage. As a general rule, group plans are much less costly to all parties.
Disability income protection should be an element of your entire financial planning. The importance cannot be overestimated because it relates to your overall family finances. Whatever you situation may be, disability is one of the most important factors when you consider you inability to work and produce income.
Some things to consider when determining disability income needs are:

• Establish the bare minimum required if income stops.

• Determine your retirement needs if work ceases and the ability to pay into the retirement ends.

• Allow for any benefit that might be offset by social security and workers compensation.

Some thought needs to be afforded to the possibility of “total
disability.” That definition is important as it is always defined in a policy and different companies may use different definitions.

Interpretation is important as it pertains to the insured’s own occupation and any occupation the insured may be qualified to perform.
The first method used to determine total disability concerns the occupation that the insured is normally engaged in. In this case total disability might be defined as “the insured’s inability to perform any or all of the duties or his or her own occupation.” This is determined by the insured’s occupation at the time that disability begins.
The second method is more restrictive defined as “the insured’s inability to perform the duties of any occupation for which he or she is reasonably qualified by education, training or experience.”
In other words, while you may no longer be able to conduct the duties of your current occupation you may be able to perform activities in a related field.
There are some disability income policies that use another criterion to classify total disability. This is called presumptive disability and automatically qualifies the insured for total disability classification. These conditions are:

• Loss of use of any two limbs

• Total and permanent blindness

• Loss of speech and hearing

Presumptive disability may also be decided by using a loss of income test. If the earnings after disability significantly drop below pre-disability earnings by a given percentage the insured may be considered totally disabled.
Usually short-term policies cover non-occupational disability but most long-term policies cover both occupational and non-occupational sickness and accidents. Bear in mind, however, that occupational benefits are usually reduced by benefits received form workers compensation and social security.
Other considerations are the probationary period, elimination period and the benefit period.
Some disability policies use a probationary period that begins when a policy goes into effect and no benefits are paid during this period. It varies but is often 15 or 30 days and sometimes up to 60 days for long-term policies.
In addition to the probationary period some policies also include an elimination period. It begins when the policy goes into effect and can last for any length of time even up to a full year. This is usually left to the insured to decide as it is based on how long the insured can go without income after becoming disabled.
The primary advantage to a long probationary period is a low
premium and allows the insured to use premium dollars to purchase a benefit that best suits their needs.
The benefit period, which is the length of time, can vary depending on the needs of the insured. They can be as short-term as 13 weeks up to long-term as long as age 65.
As a general rule the longer the benefit period, the higher the premium. Same as everything in life, we get what we pay for.
Benefit amounts for both short-term and long-term policies range from 50% to 66 2/3% of earnings with a cap on the maximum amount to be paid.
Other disability categories are confining vs. non-confining, partial, residual, recurrent, delayed, combined accident and sickness and non-disabling.
We won’t cover definitions of each category here, but do be aware of their existence and check your policy for a definition of coverage for these types of disability.
Most companies offer optional short-term benefits for an additional cost. A typical disability income policy might include all, some or none of the items below so it is important to discuss these with your agent. These options are:
Supplemental income – sometimes called an additional monthly benefit rider, provides additional income during the first several

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DIFFERENT TYPES OF HEALTH INSURANCE POLICIES

Health insurance is a legal contract between two or more parties that promises certain performance in exchange for considerations. A health insurance policy is considered a unilateral contract. This is because only one party (the insurer) is required to fulfill their obligation. While a policy owner may decide to terminate premium payments, as long as the payments are paid the insurer must meet their responsibility under the contract.
A health insurance policy can provide just one or any combination of certain benefits:

• Hospital, medical and surgical expenses resulting from sickness or an accident

• Accidental death or dismemberment

• Disability resulting from accident or sickness (sometimes this can also be referred to as “loss of income” or “loss of time”

An accident is an injury that occurs accidentally. A sickness is an illness or disease that is not the result of an accident. Knowing the difference is important because policies may have different provisions that apply to accidents or sickness. Also, there are some companies that sell a separate accident policy that does not include sickness.
The terms accident and sickness are widely used and often interchangeable in any discussion of health insurance. They are often abbreviated as A&H and A&S. Health insurance is also referred to as medical insurance.
As we discussed above, health insurance is designed to protect again two types of economic loss. Loss of income and expenses for medical care which places them in either of two broad policy categories:

• Disability income policies

• Medical expense policies

Disability income policies can also be referred to as loss of income, loss of time or replacement income. This type of policy will pay benefits to an insured who is disabled and can no longer work to earn a regular income. Payments can be weekly or monthly depending
on the policy.
Medical expense policies are represented by a wide range of coverage from very minimal to comprehensive packages with multiple coverage. Some include both accidents and illnesses, various hospital expenses and other costs pertaining to medical care such as:

• Accident and sickness policies

• Hospital policies

• Basic medical expense policies

• Major medical expense policies

• Comprehensive medical expense policies

Any of these policies might cover various combinations of the above and may be paid in a lump sum.
Accident Policies. Some policies cover only accidents and not illness. As you might imagine, policies like this are very specific about what is considered an accident.
It is important to understand what is defined as an accident as it pertains to the health insurance industry. . .an accident is an event that is unforeseen and unintended.
Keep in mind that any discussion of this type of policy also applies to any type of policy that includes accidental coverage not just accident specific policies.
Accident benefits are most commonly paid for accidental loss of
life (also called accidental death), accidental loss of limb or sigh (dismemberment), loss of time and/or income, hospital expenses, surgical expenses, and medical expenses like visits to the doctor.
Let’s expand a bit on dismemberment. As we said, this would be loss of limb or sight, however, different states have statutes that define dismemberment and they can vary from state to state. This is a subject that you need to discuss with your insurance agent to determine what actually constitutes dismemberment in your state.
Accidental Death Benefit can also be referred to as “principal sum.” This type of coverage should not be confused with life insurance. There is a world of difference between the two. Life insurance policies will generally regardless of the cause of death. An accidental benefit is paid ONLY if the death is accidental as opposed to a death by natural causes or illness.
The person who received the death benefit is called the beneficiary. The policy owner has the right and responsibility of naming beneficiaries. Usually there is a primary beneficiary however he/she can assign a second and even a third beneficiary.
The primary beneficiary is the first person in line to receive the benefit in the event of the death of the policy holder. They can also name a second beneficiary who would receive the benefit in the event the primary beneficiary dies before the insured. Some policies can
include a third beneficiary who would be in line after the first two.
There is much more to be learned about accidental death policies, but we would like to mention one important element before we move on. An accidental death may not be instant. A person can die as a result of an accidental injury months after the accident occurrence. Read your policy carefully because most stipulate that the accidental death benefit will only be paid if death occurs within three months of the accident.

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