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CHIP & KP HMO plans

A public payer is the federal, state, local government, or combination of government entities. The plans are funded through specific or indirect general taxes. The central government programs in the US are Medicare, Medicaid, Children's Health Insurance Program (CHIP), etc. (Cellucci, 2019). I choose to discuss CHIP. CHIP provides low-cost health insurance coverage to children and pregnant women in families who earn too much to qualify for Medicaid but cannot afford private health insurance. It is funded through a state and federal partnership; each state has different benefits. But all states provide comprehensive coverage, including routine check-ups, immunizations, doctor visits, prescriptions, dental and vision care, inpatient and outpatient hospital care, laboratory and x-ray services, and emergency services. Unlike states that opt to include coverage for eligible children under a CHIP-funded expansion of Medicaid and, therefore, must extend Medicaid-covered services to CHIP-eligible individuals, states with separate CHIP programs have flexibility in program design. CHIP premiums and cost-sharing may not exceed minimum amounts as defined by law. However, states may vary it based on income and family size, as long as cost-sharing for higher-income children is not lower than for lower-income children. Federal laws and regulations also impose additional limits on premiums and cost-sharing for children in families with incomes at or below 150 percent of the federal poverty level (Nicholson, 2014).

A private payer (non-government) is a private insurance company; each company offers plans that must meet or exceed basic standards set by the state and federal government. It may offer one or more plans (PPO, EPO, POS, HMO, etc.). Generally, lower-cost healthcare plans give patients fewer choices in doctors and hospitals. Lower-cost plans may also make it more difficult for patients to see a specialist, while some plans allow patients to see a specialist anytime. For example, if a patient has a rash, they can go directly to a dermatologist. Other insurance plans require patients to see their primary care doctor first and then get a "referral" to see a specialist. When a person has a severe injury or illness, the costs can be so high that a single person cannot afford them. If that individual has insurance, however, the premiums paid by all group members, managed by the insurance company, will defray a significant percentage of the costs. Thus, employers, employees, and individuals pay a premium contributing to a risk pool from which the costs associated with the insured's illness or injury will be paid. Employers, employees, and individuals pay the premium. According to Wagner (2021), the US has about 35 major private health insurance, each with several brands, subsidiaries, and policies. I choose to discuss Kaiser Permanente (KP) and HMOs plan. KP provides comprehensive healthcare services through a system of healthcare network facilities. All health care is arranged or provided by a primary care physician. HMO plan usually limits coverage to care from doctors who work for or contract with the HMO. It generally would only cover out-of-network care in an emergency. HMOs require one to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness (Kaiser Permanente, n.d.).

REFERENCES

Cellucci, L. (2019). Essentials of Healthcare Management: Cases, Concepts, and Skills, Second Edition: Vol. Second edition. Health Administration Press.

Kaiser Permanente (n.d.). American University. Retrieved February 14, 2023, from https://www.american.edu/hr/benefits/health/kaiser.cfm

Nicholson, M. H. (2014). Children's Health Insurance: Comparisons of CHIP Coverage: Vol. Comparisons of Children's Health Insurance Program coverage. Nova Science Publishers, Inc.

Wagner, S. L. (2021). The United States Healthcare System: Overview, Driving Forces, and Outlook for the Future. AUPHA/HAP Book.