Health Insurance Options in

the United States

HCA/210
August 8, 2010
Suzanne Mays
What is Health Care?
Insurance is purchased to protect from
financial losses in the future.
Health insurance is purchased to
protect from financial losses due to
expenses that occur from medical
services.
Can be purchased via the private
sector or publicly funded.
Can be purchased by individuals or
through employers or associations.
How Health Care Began
Franklin Health Assurance Company
of Massachusetts 1850
Accident insurance 1860
Sickness coverage 1911
Predecessor to HMO 1929
Modern Health Insurance
Health Insurance Options
Managed Care
HMO Health Maintenance
Organizations
PPO Preferred Provider Organization
POS Point of Service
TRICARE

HMOs
Health Maintenance Organizations
Advantages
No maximum lifetime payout Advantage 3
Low cost
In-network providers, gate-keeping, case
management, and pre-certification

Disadvantages
Out of network providers are not covered
Tighter controls make it difficult to get specialized
care
Will not pay for non-emergency care provided by
a non-HMO physician.
Managed Care
Insurance plans that contract with health care
providers and medical facilities

Advantages
Sometimes there is no deductible
Your co-pay may be less than POS coverage
A provider is chosen for you

Disadvantages
Pre-approval is required before starting treatment
Provider and service restrictions
Non-authorized or non-approved treatment will not be
covered
PPO
Freedom for patients to choose their own
providers.

Advantages
Ability to choose providers outside of the
network
Out of pocket expenses limited

Disadvantages
Less coverage for treatment provided by non-
PPO physicians
More paperwork and expenses than HMOs

POS
5-6 words about what POS is

Advantages
Out of pocket expenses limited
Treatment is automatically covered up to your plan
maximums.
Can choose to receive treatment from any licensed
professional.

Disadvantages
Responsible for a percentage of the fee
More restrictions on specialized care
More costs as the consumer moves away from the
managed aspects.
TRICARE
Managed care for military personnel
and their dependents

Options such as TRICARE Standard,
Prime, Extra, and Reserve Select
Options similar to HMO, PPO, or POS plans
Benefits and disadvantages similar to other
managed care
References
Fernandez, B. 2009. Health Insurance A
primer. CRS Report for Congress. Retrieved
August 6, 2010 from
http://www.law.umaryland.edu/marshall/crsrepo
rts/crsdocuments/RL3223702032005.pdf
Health Insurance, 2009. Retrieved August 6,
2010 from
http://www.agencyinfo.net/iv/medical/types/h
mo-ppo-pos.htm
Military.com, 2010. Understanding TRICARE.
Retrieved
August 6, 2010 from
http://www.military.com/benefits/tricare