I'm up past midnight to write all this and there's going to be a ton more because this isn't even the last chapter, someone please come put me out of my misery. Also Emily is sick. Which means no new chapter for a while, assuming she doesn't feel like writing while sick.
Types of Providers
The same stage directions as always. Everyone is center stage. Addie and Erick have issues projecting their voices so they get a ton of feedback from the director. Fred keeps forgetting his lines. The stage hands are freaking out because they all go on in 5 minutes for the fantastic musical known as Studying: The Musical.
BAYMAX: Hiro, have you programmed me to sing better than the last attempt?
HIRO: You'll do fine.
ANNA: Curtains in 5 minutes, everyone!
FRED: Wait, how did my bedroom suddenly turn into a theater?
HICCUP: How am I the Hiccup from 3 different canons?
FRED: Touche.
ELSA: Places!
ASTRID: Why are Elsa and Anna the crew for this show?
GOGO: I don't know my lines.
HONEY: I didn't even know we had lines.
FINN: Why am I suddenly wearing tap shoes?
Music swells from the orchestra pit.
JACK FROST: Welcome, ladies and gentlemen, to the award winning musical, Studying!
Audience applauds.
JACK FROST: I would like to remind all of you to silence your cellphones, beepers, and pagers. Also please do not use flash photography as it may disorient the actors.
CLIFF: This is like a nightmare or something. Has anyone else had this nightmare?
JACK FROST: Please note the emergency exits. And as always, we hope you enjoy the show.
The lights dim. The orchestra swells. All of the characters suddenly notice that they are attached to microphones. The curtain opens. Lines of song will be written in italics.
TADASHI: Insurance! The best thing in the world!
HIRO: Insurance! May the studying commence!
FRED: I don't know how I know the words to this song!
EVERYONE EXCEPT FRED: Don't question our overlord!
HONEY: An insurer pays for losses and provides monetary benefits!
GOGO: It also provides other services.
BAYMAX: Let us not forget the Stock and Mutual Insurance Companies.
EVERYONE: Such as Blue Cross/Blue Shield, HMOs, and PPO
ADDIE: All are examples of insurers!
They all break out into a highly synchronized tap dancing routine. Everyone leaves the stage except Cliff and Fred.
CLIFF: Say, Fred, what are Nonprofit Health Service Plans?
FRED: Allow me to tell you... in opera! Nonprofit Health Insurance Plans are those insuuuuuurers that are oooooorganized under special Staaaaate Laaaaws that exeeeempt them from some taaaxes imposed on proooofit INSUUUUURERS! To supplyyyyy Medical Expense Reimbursement Insuraaaaaaaaaaaaaaaaaaaaaance!
CLIFF: Wow! So that means that Nonprofit Health Insurance Plans are organized under State Laws that exempt them from taxes that profits insurers have to pay? You mean like Blue Cross/Blue Shield?
FRED: That... is... CORREEEEEECT!
Everyone comes on stage as the music swells in a dramatic tune.
HICCUP: This study technique actually makes it harder to remember for our overlord!
FINN: So I'm afraid this musical must end.
ADDIE: But it was fun while it lasted!
EVERYONE: So let us say good NIIIIIIIIIIIIIGHT!
The audience bursts into applause. Everyone takes a bow and the curtain closes.
BAYMAX: So let's get back to our insurance.
Everyone sits down in the same positions as if nothing ever happened. Suddenly the curtain turns into Fred's wall again, although the 4th wall jokes will continue to be rampant in this series.
BAYMAX: An HMO (Health Maintenance Organization) is an organization that complies with State and Federal requirements to provide a package of comprehensive Health Care services to individuals known as subscribers or members.
HIRO: I see what you're saying. An HMO provides a bunch of Health Care services to its members.
BAYMAX: Yes. The HMO Act of 1973 forced employers with 25 or more employees to offer an HMO as an insurance alternative to their regular Health Insurance Plans. Today, the rules of the act do not apply to employers so employers are no longer forced to offer HMO insurance plans.
TADASHI: So why bring that up?
OVERLORD KATIE: I don't know, this study material is stupid.
BAYMAX: After an HMO has been in operation for 24 months, it may offer a 30 day Open Enrollment period to accept new enrollees.
HONEY: So does that mean that after 2 years, it can enroll new people during a 30 day period?
BAYMAX: Yes. An HMO provides financing, delivery, and managing of Health care services for its members.
TADASHI: Okay so for its members, it provides things like that.
GOGO: Way to totally reiterate what he just said.
TADASHI: It needs reiterating!
BAYMAX: It is contracted with a group of doctors and other Medical practitioners to provide services at agreed upon costs that are prepaid on behalf of its members, called cost containment.
TADASHI: So cost containment means costs that Medical practitioners agree on for the services HMOs provide?
BAYMAX: Correct. HMOs offer services to members living within specific geographic boundaries that are most often formed along county lines. Individuals living within the boundaries are eligible to belong to the HMO.
HIRO: So that means that people who live in the right boundaries can be part of the HMO.
BAYMAX: An HMO makes efforts to limit its costs by providing care only from physicians that meet the HMO's standards and qualifications and are willing to provide care at a pre-negotiated price.
HICCUP: Okay so it tries to save money by providing care from only doctors who meet the standards and qualifications and are willing to provide care at a lower or pre-negotiated price.
BAYMAX: Correct. When a member joins an HMO, they are asked to choose a Primary Care Physician (gatekeeper). An HMO plan with the gatekeeper system allows policyholders to see specialists by obtaining a referral from their Primary Care Physician.
ASTRID: So they choose a gatekeeper who refers them to specialists?
BAYMAX: Yes. In an HMO, a co-payment is a set $ amount that the member is asked to pay.
GOGO: So like a member can be asked to pay like $20 for each office visit.
BAYMAX: Correct. The amount paid annually may not exceed 200% of the annual premium. Managed Care Health plans like an HMO are paid on a prepaid basis.
ADDIE: Like the cellphone analogy.
ERICK: So doctors would be paid regardless of whether or not the insured visits them?
BAYMAX: Right. Members of an HMO are encouraged to get regular checkups for early detection of medical problems. An HMO must provide Preventative Care.
TADASHI: They're encouraged to go to doctors to prevent major health problems later on.
BAYMAX: That is a simplified version of what I just said. But correct. In an HMO Physician System, the physician that the member selects to provide all their care is their Primary Care Physician.
HIRO: Yeah. Like Dr. T for Overlord Katie?
BAYMAX: Yes. Even though she visits other doctors, he is her primary care doctor. And were she using an HMO, he would have to refer her to the other doctors.
FRED: So can an HMO member get emergency care even if they're out of the service area?
BAYMAX: Yes they can. And they can call a physician that can help the insured receive medical care.
FRED: Cool!
BAYMAX: Urgent Care includes Medical services for illnesses or injuries that are not life threatening but require care within 24 hours.
TADASHI: So can they get care outside of the area to prevent further deterioration of the condition?
BAYMAX: They can. An HMO member is provided inpatient Hospital Care in or out of their service area for at least 90 days per year. Treatment for a disorder or for Drug or Alcohol rehab is 30 days per year.
HIRO: So they're allowed 90 days a year for a disorder and 30 days for rehab.
BAYMAX: Correct. The HMO must have a Customer Service Center to handle inquiries and complaints about Patient Care or other coverage concerns.
GOGO: That must be a fun place to work. All the complaining they hear all day long.
BAYMAX: In an Open Panel HMO arrangement, any physician may provide HMO services to their members as long as their requirements are met.
HICCUP: So they can see any doctor?
BAYMAX: Yes. In a Closed Panel HMO arrangement, physicians are selected and paid as HMO employees to provide services to their members.
HICCUP: So no choice, just the doctors available.
BAYMAX: There are 4 different types of HMOs.
GOGO: Ugh, why are we not done?
OVERLORD KATIE: I'm with her, it's taken days to type all this up and there's still a zillion more pages to go.
BAYMAX: Please be patient. Remember that there are sections of this chapter that are a lot shorter.
OVERLORD KATIE: True...
BAYMAX: In a Group Model, an HMO utilizes and pays a group of physician specialists instead of individual doctors.
HICCUP: So they pay a group instead of just the doctors. Like a fixed monthly amount? But that would require risk because it will profit if few members use it and not if many do.
BAYMAX: That is correct. An Independent Model provides the largest selection of independent physicians, Medical groups, and associations that provide services from their own private offices.
HICCUP: And doctors would be paid on a negotiated fee?
ASTRID: You're getting good at this.
BAYMAX: The Network Model provides services from 2 or more Medical groups and private physicians.
HICCUP: So the services are 2 or more medical groups and physicians. Probably paid a capitation fee for their services. Which is the term above in the group model, the fixed monthly amount.
BAYMAX: Correct again. The Staff Model pays physicians that are HMO employees to provide services to their members in their facilities.
HICCUP: So the HMO people's HMO for services within their own offices.
BAYMAX: Essentially, yes. This concludes the second part of chapter 5.
I really want this to be over already.
~KateMarie999