CH 12- Health Insurance Essentials

EPO

Combines aspects of HMO and PPO. Not covered for services outside of the designated network of providers. Not required to choose a PCP. May not need a referral for specialized care.

TRICARE

Comprehensive healthcare program for uniformed service members and retirees and their families. Managed by military in partnership with civilian hospital and clinics. Designed to: - expand access to health care - ensure high-quality care - promote medical readiness 2 types of TRICARE plans: - TRICARE Prime - TRICARE Select

Liability i surance

Covers losses to a third party caused by insured. Types: - automobile - business - homeowners Often include benefits for: - medical expenses resulting from traumatic injuries - lost wages - sometimes pain and suffering

Medicaid recipients:

Eligibility is determined by respective states; most recipients are: - low-income families - qualifies pregnant women and children - Recipients of Temporary Assistance for Needy Families (TANF) - individuals who receive Supplemental Security Income (SSI) - individuals who receive certain types of federal and state aid - individuals who are Qualified Medicare Beneficiaries (QMBs) - individuals in institutions or receiving long-term care

3 types of private health insurance plans

Employer group plans Self-funded group health plans Individual health insurance plans

EOB?

Explanation of benefits A document sent by the insurance company to the provider and patient explaining the allowed charge amount, the amount reimbursed for services. And the patient's financial responsibilities.

Government health insurance plans

Patients qualify by age, income, government occupation, and health condition. - Medicare - Medicaid - TRICARE - CHAMPVA

Precertification vs Preauthorization

Precertification specifically determines whether the procedure is medically necessary. Preauthorization gives the provider approval to render the medical service.

Disability insurance

Provides income replacement if patient has a disability that is not work related. - Short-term disability: unable to work 9 to 52 weeks. - Long-term disability: pick up when short term benefits are exhausted. Pay out until patient returns to work or for number of years specified in policy.

Life insurance

Provides payment of a specified amount upon insured's death, either to his or her state or to a designated beneficiary. Healthcare facility may be required to complete physical examination forms when a patient is applying for life insurance. If there is an annuity policy, provider may have to determine if there is a permanent disability and submit documentation.

3 types of referrals

Regular referral: 3-10 working days Urgent referral: about 24 hours STAT referral: can be approved online; emergency

Long-term care insurance

Relatively new Covers a broad range of maintenance and health services for chronically ill, disabled, or developmentally delayed individuals. Medical services may be provided on inpatient or outpatient basis, or at home.

RBRVS?

Resource-Based Relative Value Scale Fee schedules system consist of 3 parts: - provider work - charge-based professional liability expenses - charge-based overhead

Utilization Management vs Utilization Review

Utilization management: form of patient care review by healthcare professionals who do not provide the care but are employed by health insurance companies. Utilization review committee: reviews individual cases to ensure medical care services are medically necessary. MA should contact committee, not patient.

Contracted fee schedules

When setting up a fee schedule, a healthcare provider considers: - time - expertise - services Providers must place an estimate on value of services. Allowable charge: max dollar amount that insurance plan will pay for procedure/service.

Individual health insurance plans

You buy it yourself. Not through work, government, etc. Policy can cover just one person or a family. Purchased though a health insurance exchange or directly from an insurance company. Premiums generally higher than a group plan.

Preventative care services:

- alcohol misuse screening - blood pressure screening - cholesterol screening - colorectal screening - depression screening - diabetes type 2 screening - diet counseling - hepatitis B and C screening - HIV screening - immunization vaccines - lung cancer screening - obesity screening and counseling - tobacco use screening - STI prevention counseling

10 categories of essential health benefits:

- ambulatory patient services - hospitalization - mental health and substance use disorder services - prescription drugs - preventive and wellness services; chronic disease management - emergency services - maternity and newborn care - rehabilitative and habitative services and devices - laboratory services - pediatric services, including oral and vision care Other services can be covered.

Obtaining precertification

- call provider services number on back of patient's health insurance ID card - provides insurance company with procedures and/or services requested and the diagnoses - documents the outcome of call in patients health record, including precertification number Doesn't guarantee will be paid.

Managed care organizations (MCOs)

- health insurance companies whose goal is to provide quality, cost-effective care to its members - negotiate reduced rates with contracted providers and hospitals - many require patients to choose a PCP - require referrals - preauthorization process can further control patient care

The health insurance ID card includes:

- health insurance company - health plan name and type - subscribers name and covered dependents - subscribers ID number - copay amounts - policy group number - health plan contact phone numbers

Purpose of health insurance

- help individuals and families offset costs of medical care - defined as contract for protection against financial losses resulting from illness or injury - provides payment of monetary benefits for covered sickness or injury, depending on policy purchased - policy is purchased with a premium or payment

Traditional health insurance

- pay for all of a share of the cost of covered services. - fee-for-service plans - provide most flexibility for patient - costliest - fee schedule amounts can be determined by process called usual, customary, and reasonable (UCR): amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same of similar service.

4 parts of Medicare

1. Part A covers inpatient hospital charges. No premium. 2. Part B covers ambulatory care, including primary care and specialists. Pay monthly premium, can visit specialist without a referral. 3. Part C is an option for Medicare qualified patients to turn their part A and B benefits into a private plan that can offer additional benefits. 4. Part D is a prescription drug program, requires additional monthly premium. Basic coverage for part B is 80% of the allowed amount after deductible. RBRVS (Resource-based relative value scale) determines the allowed amount.

Medicare

A federal health insurance program, also world's largest insurance program. Administered by the Centers for Medicare and Medicaid Services (CMS), a division of the Department of Health and Human Services (HHS). Qualify: - 65 and older - disabled - diagnosed with end-stage renal disease (ESRD)

Define policy

A written agreement- insurance company agrees to pay the patient if certain circumstances occur.

Define premium

Amount paid/to be paid by the policyholder for coverage under the contract, usually in periodic installments

2 types of health insurance plans

Government health insurance plans Private health insurance plans

Medicaid (in Hawaii, Quest program)

Government program that provides medical care for indigent (poor, needy, impoverished), funded by federal and state governments. Mandatory Medicaid benefits: - inpatient and outpatient hospital services - nursing facility and home health services - early and periodic screening - physician services - rural health clinic services - family planning services - transportation to medical care - tobacco cessation counseling for pregnant women

Employer group plans

Group policy, private health insurance plan purchased by an employer for a group of employees. Typically the employer pays a certain percentage of the premium for full time employees. Employers determine benefits. Premium is usually lower than an individual plan due to large pool of employees. Premium often paid through payroll deductions.

Civilian Health and Medical Program of the Veterans Administration (CHAMPVA)

Health benefits program similar to TRICARE. Provides coverage for families of veterans who were permanently disabled or killed in the line of duty. Department of Veterans Affairs (VA) shares costs of certain healthcare services and supplies with eligible beneficiaries.

HMO

Includes preventative care. Goal is to reduce cost of health care while still providing quality care. Regulated by HMO laws. Patients not required to pay deductible or co-insurance. Premiums are low. Have to pick PCP. Always requires visiting PCP for referral to specialized care. Need to see PCP for referral. If goes outside of HMO's provider network, patient pays 100% of the cost. Always requires precertification and preauthorization for hospital admissions, outpatient procedures, and treatments.

Affordable care act of 2010 (Obamacare)

Increased quality, availability, and affordability of private and public health insurance for more than 44 million uninsured Americans. Works to reduce overall healthcare spending in the long run. Insurance companies cannot drop patients health coverage if individual gets sick or makes unintentional mistake. Preexisting conditions eliminated.

Workers Compensation

Insurance plan for individuals who are injured on the job or become ill due to job related circumstances. As long as employee wasn't negligent. Covers: - medical care and rehabilitation benefits - weekly income replacement benefits - death benefits to dependents

Self-funded group health plans

Large companies or organizations have enough employees that they can fund their own insurance program, a self-funded plan. Employer pays employee healthcare costs from the funds collected from employer monthly premiums. Often a third-party administrator (TPA) handles paperwork and claim payments for a self-insured group.

PPO

Managed care network that contracts with a group of providers- they agree on a predetermined list of charges for all services. Fee-for-service. Flexible benefit design. Patients financial responsibilities around 20-25% of allowed charge. Do not need to see PCP for referral. If patient goes to a provider that is not in the PPO network, the deductible, coinsurance, and copayment will be higher.

Medically necessary vs elective procedures

Medically necessary services are those that are necessary to improve patients current health. Elective procedures are no deemed medically necessary.

Government managed care plans

Medicare and many Medicaid programs offer their members an option to join a managed care plan. ID cards look like cards issued to people who are not on Medicare or Medicaid. May have a copayment.

Cost-sharing

Most policies require patient to pay portion of healthcare expenses. Includes: - deductible: set dollar amount that the policyholder must pay before the insurance company starts to purchase pay for services. The higher the deductible, the lower the premium - co-insurance: after the deductible has been met, the policyholder may need to pay a certain percentage of the bill, and the insurance company the rest. Typically 80/20 - copayment: a set dollar amount that the policyholder must pay for each visit. May differ for different types of office visits.

PARs

Participating provider. Healthcare providers must become a PAR to contract with all government health plans and most private health plans. Applying to become a in-network PAR is called credentialing. Agree to take insurance's fee schedule.

Models of managed care organizations (MCOs)

Patient care is coordinated through network of providers and hospitals. Types: - health maintenance organizations (HMO) - preferred provider organizations (PPO) - exclusive provider organizations (EPO)

Children's Health Insurance Program (CHIP)

State-funded program for children who's family income is above Medicaid qualifying income limits. Premiums typically 5% of family monthly income. Some programs cover: - routine checkups and doctor visits - immunizations and prescriptions - dental and vision care - inpatient and outpatient hospital care - laboratory tests and x-ray services - emergency services

Verifying eligibility

The process of confirming health insurance coverage for patient. Medical assistant should gather health insurance information and verify effective date. Then, review insurers online insurance web portal. Once approved, a patients benefits can be looked up in their entirety in seconds.

2 types of health insurance models

Traditional health insurance managed care organizations