Week 14

Private Fee-for-Service (PFFS) Plans

A PFFS plan is a type of Medicare Advantage plan whose coverage can, in many ways, offer the most flexibility. Enrollees can choose their own doctors and hospitals and the benefits covered are quite extensive. Inpatient and outpatient services, equipment and home health services all are covered, as are preventative services and diagnostic testing. The enrollee's doctor or hospital must agree to accept the plan's terms and conditions prior to providing health care services with the exception of emergencies. If the doctor or hospital does not agree to accept the payment terms and conditions, they may not provide health care services to the enrollee, except in emergencies.

HEDIS HealthCare Effectiveness Data Information Set

A core set of standard performance measures for managed care in the areas of quality, access and patient satisfaction, membership, utilization, finance, and health plan management is called:

true

A fee schedule is a flat rate per procedure, visit, or service. Negotiating a fee schedule allows more consistent budgeting of payment dollars by the managed care organization.

false

All individuals eligible to receive care with the managed care organization (MCO) are referred to as residents.

false

Coordination of benefits (COB) allows excess reimbursement from health plans to providers to be refunded to the patients.

TJC

Each part of the entity may be individually accredited by this organization.

economic creditialing

Ensuring that a provider is not underutilizing services and compromising the health of managed care members or overutilizing services and creating unnecessary expense is:

The main disadvantage of a Medicare Part C Advantage plan is that the choice of doctors and other healthcare providers is limited. Other restrictions on access to care may apply as well.

Finally, a Medicare Part C plan can drop out of a geographic area at any time, leaving enrollees with only a few options for switching coverage.

Health savings account

Funds set up by an employee that is not taxed when the employee withdraws from the account for medical expenses. Amounts left in the account at the end of the benefit year roll over to the next year. Withdrawals for nonmedical expenses are subject to income tax and a 10% penalty.

Staff model HMO

HMO entity that owns the facilities and arranges for health care through employed providers.

Independent practice association model HMO

HMO model that was developed as a way for solo practice physicians to participate in the managed care market.

Network model HMO

HMO that contracts with more than one physician group, hospital, and other facilities to provide a comprehensive health care package.

Group model HMO

HMO that has an exclusive contract with one multi-specialty medical group that provides all physician services.

Mixed model HMO

HMO that operates within two or more different types of organizational structures to provide flexibility to members and diversity of income to the HMO.

Medicare Advantage plans come in five (5) types. All of them operate under the same rule: Enrollees get full coverage only if they see healthcare providers who are members of the plan's network. However, each provides certain variations to basic HMO rules. The five types are:

Health Maintenance Organization (HMO); Preferred Provider Organization (PPO); Private Fee-for-Service (PFFS) Plans; Medicare Special Needs Plans (MSN); and Medical Savings Account (MSA).

Medicare Advantage (Part C) Plans, sometimes called "Part C" or "MA" Plans, are health plans offered by private companies approved by Medicare.

If a Medicare beneficiary joins a Medicare Advantage Plan, the plan approves manages all Part A (hospital insurance) and Part B (medical insurance) coverage

a Medicare managed care program

Medicare Advantage (formerly Medicare + Choice) is:

health maintenance organizations (HMOs) and preferred provider organizations (PPOs), and through new mechanisms such as medical savings accounts (MSAs).

Medicare Advantage expands options for receiving Medicare coverage through a variety of private insurance plans, including

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 changed the name of the Medicare+Choice Program to

Medicare Advantage in 2004.

true

Medicare managed care plans receive payments under the Medicare Advantage program for enrollees who have both Part A and Part B coverage.

nurse practitioners

Mid-level providers are often used in managed care to provide illness-related services to patients; they include: physicians case managers health edicators nurse practitioners

true

Preventive care and wellness are a central focus of a health maintenance organization and most managed care organizations.

Flexible spending account

Tax-free money an employee set aside to use during a specified period for health care expenses; funds cannot be used for nonmedical purposes; funds not used are returned to the employer at the end of the benefit period.

coinsurance

The 20% expense that is the responsibility of the insured under an indemnity insurance policy is called:

The Balanced Budget Act of 1997 ( BBA), signed into law on August 5, 1997, divided the Medicare program into multiple financing and delivery systems.

The BBA accomplished this by creating a new Medicare Part C, also called the Medicare+Choice program.

true

The Clinical Laboratory Improvement Amendments (CLIA) requires that every laboratory possess a certificate to operate and that laboratories that fail to meet the operational standards or proficiency testing guidelines have sanctions imposed.

false

The MCO negotiates per diem rates with individual physicians.

deductible

The amount of medical expenses that insureds must pay each year from their own pockets before the plan will reimburse them is called the:

referral

The authorization to receive a specific health service from a specific health provider is called a(n):

gatekeeper

The managed care primary care provider (PCP) who coordinates all patient health care needs and decides what, if any, additional care or testing is required is acting as a(n):

Why do Medicare beneficiaries look at managed care plans? The main benefit is cost. Total out-of-pocket expenses with a Medicare Part C plan are usually lower than with traditional Medicare Parts A and B plus a Medigap insurance policy.

The other benefit is usually slightly broader coverage of services than regular Medicare provides.

dependent

The spouse or child of the primary recipient of the managed care insurance benefit within a managed care organization is referred to as a:

Preferred Provider Organization (PPO)

These plans offers slightly higher co-payments than most HMO plans, combined with the freedom to choose doctors and hospitals that are within the provider network as well as choosing providers that are not. Once enrolled, beneficiaries receive a directory of providers that participate in the network. If an enrollee chooses to see a doctor or hospital that is not part of the network, they may do so, however they would be required to pay additional out-of-pocket costs instead of just the minimal co-payment (except in the case of emergency or urgent care.)

As you've read in this lecture, Medicare Advantage Plans are a way to get combined Medicare Part A and Part B benefits, and in some (if not most) cases, prescription drug coverage (Part D).

They may also provide more coordinated health care to help keep beneficiaries healthy and lower costs. Some plans (like HMOs) might use networks, where an enrollee may only be able to see certain doctors or go to certain hospitals.

concurrent review

Verifying medical necessity of tests and procedures ordered during an inpatient hospitalization is called:

A managed care organization that meets TJC and AAAHC standards is deemed to meet NCQA standards.

false

The resource-based relative value scale (RBRVS) system is an example of per diem reimbursement.

false

Medicare Special Needs (MSN) PlansThis is a special type of Medicare Advantage Plan that provides all Medicare Part A and Part B health care and services to people who can benefit the most from things like special care for chronic illnesses, care management of multiple diseases, and focused care management. These plans may limit membership to people:

in certain institutions (like a nursing home); eligible for both Medicare and Medicaid; and with certain chronic or disabling conditions.

A provider's panel is a group of patients who have chosen the provider as their primary care provider (PCP).

true

Capitation is the payment of a fixed dollar amount for each covered person for the provision of a predetermined set of health care services for a specific period of time.

true

The managed care organization (MCO) produces its revenue by selling an insurance product and must reimburse providers for services delivered to members.

true

When a provider agrees to see managed care organization (MCO) patients and to subtract a certain percentage from the regular fee-for-service rate, this is called discounted charges.

true

false

An employee who is injured on the job must receive care from a provider selected by the workers' compensation carrier.

Many people find a Medicare Part C managed care plan a good alternative to traditional Medicare Part A and Part B coverage. In addition to providing the same coverage as Parts A and B, a Medicare Part C plan also provides some of the extra coverage of a Medigap insurance policy.

Because of the expanded coverage a Medicare Advantage plan provides, purchasing a Medigap policy is unnecessary.

Health Maintenance Organization (HMO)

If having the lowest co-payment for doctor visits is at the top of a Medicare beneficiary's priority list, this is the plan they will probably enroll in. An HMO plans offer low co-payments (and, in some cases, no co-payments at all) and no deductibles. However, enrollees are required to receive a referral from their Primary Care Doctor before seeing any specialist, and to receive full benefits, they are required to use doctors and hospitals that are within the HMO network. If the choice is made to not to use in-network providers, the enrollee may be responsible for all of health care expenses.

true

In the staff model HMO, the HMO entity owns the facilities and arranges for health care through employed physicians, who are allowed to see only the particular HMO's patients.

Preferred Provider Organization

Insurance entity that contracts with providers to create a network, resulting in lower costs of services to patients.

Health maintenance organization

Insurance entity that provides or arranges services for a covered population who prepays a fixed premium.

Point of Service Plan

Insurance plan that combines prepaid health services with network providers, creating levels of out-of-pocket cost options for the insured.

Managed Indemnity Plan

Insurance plan that reimburses the insured for expenses incurred, but incorporates some managed care principles to help control costs.

Medical Savings Account (MSA)

This is typically the most popular Medicare Advantage plan available, and the one most often recommend. This plan combines a high deductible health plan with a medical savings account. Medicare puts money in this savings account, which can then be used to pay the enrollee's deductible or cover other out-of-pocket medical expenses like dental, eyeglasses, or even alternative care like acupuncture or homeopathy. When the money in the account is used for Medicare-covered Part A and Part B services, it counts toward the deductible, which, as stated, is a high deductible. However, once the deductible amount is met, the plan covers all Medicare-covered services. Enrollment in an MSA plans provide enrollees with more control over their health care utilization, while still providing coverage against catastrophic health care expenses.

AAAHC Accreditation Association for Ambulatory Health Care

This organization accredits HMOs at each clinic site, but not as an HMO.

NCQA National Committee for Quality Assurance

This organization accredits managed care organizations and related services, including health plan accreditation, wellness and healthy promotion, managed behavioral health care organizations, and disease management.

URAC Utilization Review Accreditation Commission

This organization offers Health Plan accreditation for the HMOs and Health Network accreditation for PPOs.

since its inception, Medicare has provided a set of coverage and due process protections so that all beneficiaries could expect the same basic level of health insurance.

This system resulted in the evolution of an imperfect, but functional, basic health insurance program for all.

With a Medicare Advantage HMO, enrollees are covered for the same healthcare as they would be under Medicare Parts A and B. And many Medicare HMOs add care that isn't covered by Part B. But a Medicare Advantage HMO also has important restrictions. These are:

To get coverage, enrollees must obtain care only from doctors, hospitals, and other healthcare providers who belong to the HMO's network - meaning they're under contract with the HMO; The HMO won't pay for care by a specialist unless referred by the enrollees' HMO-network primary care physician; Enrollees might not be covered for certain kinds of care unless the HMO approves that care in advance; and Enrollees have very limited rights to appeal a decision made by the HMO.

Anyone who is eligible for Medicare Part A and Medicare Part B can join a Part C Medicare Advantage plan instead. To join one, though, the plan's insurance company must be offering it in the beneficiary's geographic region -

usually a county or group of counties - where potential enrollees live. And that particular plan must be accepting new members.

Medicare Advantage Plans may offer extra coverage for items not typically covered by Medicare, such as

vision, hearing, dental, and/or health and wellness programs. Most plans also include Medicare prescription drug coverage. Regardless of the extra coverage options, all must follow the set rules of Medicare.