Скачать или смотреть Fee-for-Service Plans

Three main types of long-standing health insurance programs are fee-for-service plans, managed care plans, and point-of-service plans, with large employers often offering more than one option. Fee-for-service plans reimburse the insured or provider for covered medical expenses, typically including hospital, surgical, and physician services, and allow patients to choose any licensed provider. Indemnity plans are purchased from insurance companies, while self-funded plans are financed directly by employers, though both operate similarly in coverage.

Hospital benefits may be for inpatient or outpatient care, surgical benefits cover medically necessary procedures within usual, customary, and reasonable charges, and physician benefits cover hospital or office visits, sometimes including home visits. Cost-control provisions include deductibles, coinsurance, out-of-pocket maximums, preexisting condition clauses, preadmission certification, second surgical opinions, and maximum benefit limits. Deductibles require the insured to pay a set amount before coverage starts, while coinsurance splits covered expenses between insurer and insured, often 80/20.

Out-of-pocket maximums limit total yearly expenses beyond the deductible, protecting individuals from catastrophic costs. Preexisting condition clauses limit coverage for conditions treated before coverage began, though federal law restricts their use; preadmission certification and second surgical opinions aim to control unnecessary hospitalizations and surgeries. Comprehensive major medical plans have replaced many traditional fee-for-service plans, offering broader coverage and a single deductible to reduce duplication of benefits.