Today, Health insurance plan is an important of life that everyone must have. My health insurance plan is the Preferred Provider Organization (PPO), which is an individual policy cover. This plan has a number of In-network service providers that a client can choose and other Non-participating Out-of-Network providers. The insurer works with the services providers on a contractual basis in order to ensure treatment of the clients. This policy requires payment of premium in order to qualify for the services. The cost of this insurance policy or the premium is $500.00. The policy is an individual policy and since I am not in employment, I have to pay the premium by myself. This means that there is no percentage to be paid by an employer. Qualification for this health insurance plan is simply the ability to pay the premium. However, coverage costs defer according to age limits. I therefore qualify for the same.
When I receive a service, calculations are made as per the predetermined costs of the plan. This insurance plan stipulates costs for each service received and the coverage limits. Therefore, when I receive a service, calculations are made as per the policy, paying co-insurance or co-pay accordingly. This means that the bill is generated and I get a copy and the insurer settles the rest. The service provider has the responsibility to follow up with the insurer, through necessary steps in order to claim for the payment of services. In case of deductibles, the insurance does not anything for the services, giving me the responsibilities to make payments. However, it is easier working with the In-Network providers because they handle the paperwork. On the other hand, getting services from Out-of-Network providers requires filling claims.
This PPO type of insurance is only valid as long as a student is part of the University. Therefore, when the holder transfers to another institution, then the cover will cease to be operational. However, as long as the holder is a member of the university, the plan provides the cover. The cover also requires that the holder be a resident of State of Wisconsin.
Strengths and Weaknesses
PPO’s first strength comes from the wide variety of providers at the disposal of the client. It gives me the freedom to choose from a number of In-Network and Out-of-Network providers. This also means that a client can get quality service for special health cases that require specialists. Secondly, I have the liberty to choose a doctor who can handle a specific health condition. On the same note, there is no need for a referral when it comes to visiting service providers within the network, something that works to make it easier in accessing health services. It reduces the time taken in making formal referral applications in order to get services from better service providers. Third strength comes from the fact that a client has the liberty to choose the primary healthcare provider; however, the client is not tied to only the provider. There is liberty to visit other providers, depending on the type of care required. This plan allows for negotiations when it comes to the payment of the services. In the end, the person with the plan ends up paying lower amounts than the person who opts for the fee-for-service system.
However, certain weaknesses make PPO unattractive to a number of people. The first one is evident where the client enjoys cheaper healthcare rates only for the services provided within the network. In case of services Out-of-network, the client has to pay more than the normal rates. Paying full rates of the medical fees from services out of the network of providers make the whole plan expensive. Secondly, certain charges like deductibles, co-insurance and co-pays make the whole process expensive. In general, the plan provides for the freedom to seek for services out of the network; however, the system makes this impractical by the introduction of the deductibles. Lastly, PPO does not allow for service provision unless the client meets a certain limit of the deductibles. The co-insurance is an added burden after the deductibles have been met. In my case, I have to part with, between 40-50% of the cost in co-insurance arrangements, especially from the out of network service providers. The cost is further increased by the out-of-pocket expenses.
Reduce Costs to Employer
As a CEO in health insurance Company, I would find out some of the best healthcare providers, negotiate with them on some of the basic services. Today, the health conditions have changed, leading to the demand for services that require higher costs. Therefore, the best way would be to identify some of the providers and work out a plan on how to approach different health conditions as the baseline for setting premiums and other costs. I would come up with certain incentives that make the whole policy attractive. For instance, certain check-ups would cost less. It is a fact the changes in premium would affect both the employers and employees; however, the cost of healthcare provision continues to rise worldwide. Therefore, the cost should be shared between the employees and employers in order to lessen the burden for both parties.
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