Assignment 4

what is the point of service plan?

the PCP is at the center of the this plan. preferred benefits are available only for care rendered by or coordinated through the members PCP care given by a non-network doc is payale ant the nonpreferred benefit level. therefore the PCP acts as a gatekeeper to specialist care .

what are the basic features of an HMO

1 no annual deductible and small office copayments 2 comprehensive coverage with small copayments 3 no claims forms or other paperwork to file 4 preventive care, well baby care, immunizations and routine exams

what features can be used to evaluate the differences between types of managed care plans and fee for service plans

1 degree of freedom of choice 2 degree of steerage 3 responsibility for claims processing 4 degree of external utlization managment controls 5 referral mangement 6 provider reimbursement methodds 7 whether the patient is responsible for balance billing 8 rating and financial methods

what are the 3 types HMO model

1 group model 2 staff mode 3 IPA model or open panel plans

what helps members in a POS plan stay within the network?

1 no deductible 2 100% coverage after a copay 3 covered preventive care if done by PCP 4 covers 1 gyn exam 5 no claim would be submitted when the PCP renders care or coordinates care within the network 6 PCP directs medical care and obtains necessary precertification for hospital confirments and referral care

Managed indemnity plans have now applied various stand alone utilization management programs, these are some Utilization management programs:

1 precertification of inpatient admissions 2 concurrent review of ongoing confientments for medical necessity 3 discharge planning 4 precertification for selected outpatients services 5 second surgical opinions 6 case mangement for high dollar cases

the disincentive approach to PPO design

Primary approach for cost savings. Preferred benefits remain at same deductible but non preferred benefits being paid at a lower percent.

managed indemnity plan

a fee for service plan that is vitually identical to standard indemnity but has a basic utilization management program.

what is an EPO

a self funded HMO this HMO allows the plan sponsor more flexibiltiy. it can be directly sponsored or it may sell its nework and UM services to a TPA or smaller ins company. these types of "rental" arrangements are common

staff model hmo

docs are employed by the plan. will deliver all levels of care although the HMO may contract with certain specialists or facilities to provide services it cannot handle

EPO

exclusive provider organization

standard indemnity

fee for service plan with no network restrictions and no utilization management

group model hmo

hmo tht ontracts with docs and link the group with various forms of risk sharing . docs are not employed by plan

what is the main difference between HMOs, PPOs and POS plans?

in HMOs...the member gets no coverage for medical care or tretment received outside of the HMO except in emergencies. in both POS and PPO plans, the member can still get care out of network and receive benefits through a reduced rate

what helped PPOs to grow?

increase the monitoring of utilization, implementing quality control and surveying member satisfaction

what does the term managed care relate to?

it is best understood as a cange in the process of health care delivery rtaher than as distinct products fee for service arrangements, integrated treatment method, a change in the process of health care delivery

What is the Health Maintenance Organization Act of 1973?

provided federal initiatives to encourage the establishment of HMOs also known as the health maintenance strategy offered federal grants and loans to orgs wishing to investigate the feasibility of federally qualified HMOs

Steerage

the manged care company's way of directing members to in network providers. this happens by setting benefit differentials between in and out of network care between 10% and 30%

what is the chief complaint against PPOs?

they are a weak form of managed care with rich benefits and are more expensive than HMOs

combination approach to PPO design

this approach works best for the plan sponsor that wants to intoduce a managed care plan with some improvement in benefits while saving money the preferred benefits at a higher level while non preferred lower

IPA model HMOs

this plan contracts with individual practice associations or directly with private practice docs. this the most common form of HMO structure today because it needs less capital to establish and operate than other types of plans

Describe the history of PPOs

this type of organization was sponsored by insurance companies, TPAs and hospitals for their customers as an alternative to compete agains HMOs. popular because of cost savings and more choices in provider listings

why were PPOs initially unpopular?

too little emphasis on utilization control and too focused on discounted fee for service arrangements

the incentive approach to PPO design

used when the plan sponsor's primary goal is to introduce a managed care plan with the least amount of employee disruption offers richer benefits stratgically. covers a greater percentage of coverage (ex 80% vs 100%) for preferred benefits