Comprehensive Health Insurance
Health Maintenance Organization (HMO)
A health maintenance organization (HMO) is a prepaid medical service plan that provides services to plan members.
Managed Care Plan
A managed care plan is a plan that involves financing, managing, and delivery of health care services. Typically, it involves a group of providers who share the financial risk of the plan or who have an incentive to deliver cost-effective, quality health care services.
Accountable Care Organization (ACO)
Accountable care organizations are groups of doctors, hospitals, and other health care providers who organize into a group to provide care to Medicare patients. The goals of this type of organization are to provide Medicare beneficiaries with the right care at the right time, prevent duplication of services, and prevent medical errors.
Why is Blue Cross and Blue Shield plans historically important in healthcare reimbursement?
Blue Cross and Blue Shield were the first prepaid health plans in the United States.
Civilian Health and Medical Program of the Department of Veterans' Affairs (CHAMPVA)
CHAMPVA covers most health care services and supplies that are medically and psychologically necessary for dependents and survivors of permanently and totally disabled veterans, survivors of veterans who died from service-related conditions, and survivors of those who died in the line of duty.
Exclusive Provider Organizations (EPO)
Exclusive provider organizations, or EPOs, are usually developed and implemented by employer groups who are trying to control costs. The exclusive provider organization consists of medical providers, mainly physicians and a hospital, who have joined together to offer their services to specific clients.
What are the different models of integrated delivery systems?
Group Practices Without Walls (GPWWs) [Physicians keep their own offices, but share administrative and management services with other managed care organizations.] • Integrated Provider Organizations (IPOs) [An organization that manages and coordinates health care from several different providers and facilities.] • Management Service Organizations (MSOs) [Businesses that provide support services, like administration, to individual physicians.] • Medical Foundations [Nonprofit organizations that contract with physicians to manage their practices.] • Physician-Hospital Organizations (PHOs) [Organizations that provide contract health care services between hospitals and doctors. Also called "medical staff-hospital organizations."]
Children's Health Insurance Program (CHIP)
Initiated by the Balanced Budget Act in 1997, CHIP is also known as Title XXI of the Social Security Act. CHIP provides federal funds to states to expand Medicaid eligibility to include a greater number of uninsured children.
Integrated Delivery System (IDS)
Integrated delivery systems (IDSs) are health care networks that provide coordinated, organized, and comprehensive care to a community's population. Hospitals, primary care physicians, and specialists link both preventive and treatment services through contractual and financial arrangements.
When is the only time Medicare part A covers inpatient hospital care and long term care?
Medicare Part A covers inpatient hospital care and long-term care when these services are medically necessary. This means that a service or treatment is required in treating a patient, and lack of such service or treatment could adversely affect the patient's condition.
Medigap Insurance
Medigap insurance is a health insurance plan that fills the "gaps" in Medicare plan coverage. This means that Medigap covers the services that aren't covered by the Medicare options.
Preferred Provider Organization (PPO)
Preferred provider organizations represent an organization of hospitals and physicians who, for a set fee, provide services to insurance company clients. These providers are listed as "preferred," and the insured may select from any number of hospitals and physicians without the restrictions involved with an HMO.
Prepaid Health Plans
Prepaid health plans (also called prepaid medical plans) are contracts that cover specific medical expenses for individuals or groups.
What is the disadvantage of PPOs?
Success depends on the ability to recruit hospitals and physicians to participate in the plan.
TRICARE
TRICARE is a health care program available for members of the uniformed services, their families and survivors, and retired members and their families, or others registered in the Defense Enrollment Eligibility Reporting System (DEERS).
Blue Cross and Blue Shield Federal Employee Program (FEP)
The Blue Cross and Blue Shield Federal Employee Program (FEP) is the largest privately underwritten health insurance contract in the world, enrolling more than half of all U.S. federal employees, retirees, and dependents. The FEP began in 1960 when the Federal Health Employee Benefits Program was started. This program offers government workers and their dependents the widest selection of health plans in the country.
Preferred Provider Organization (PPO) vs Point of Service (POS) Plans
The FEP offers two plans—the preferred provider organization (PPO) plan and the point-of-service (POS) plan. PPOs provide discounted health care services to members in the plan, while POS members must select providers within their network to receive the discount.
Healthcare Effectiveness Data and Information Set (HEDIS)
The Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures that consumers and employers use to compare the quality of managed-care plans. HEDIS also provides information on consumers' experiences with various managed-care plans.
National Committee for Quality Assurance (NCQA)
The National Committee for Quality Assurance (NCQA) began in 1990 with a simple mission—to improve the quality of health care. Although it's a private, nonprofit organization, NCQA's dedication to improving the quality of health care has made it an industry leader.
Indian Health Service (IHS)
The goal of the Indian Health Service (IHS) is to "assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people."
What is the disadvantage of POS plans?
The insured usually pays more for this plan.
What is the main difference between an EPO and a PPO?
The main difference between an EPO and a PPO is that medical providers who join a PPO can treat any patient, whereas the EPO providers can't.
What is the "gatekeeper concept" used by HMOs?
This means that a primary care physician (PCP) or another health care worker is the case manager for the patient. All health care for each patient is directed through that case manager.
Health Insurance vs Medical Insurance
To the insurance industry, health insurance means protection against income losses for illnesses or injury, disability income, and accidental death or dismemberment (that is, loss of limbs). Medical insurance covers specific medical expenses.
Underwriting in Insurance
Underwriting is the process whereby an insurer reviews applications submitted for insurance coverage and decides whether to accept or reject all or part of the coverage requested.
Point of Service (POS) Plans
With Point of Service Plans, the insured must choose a primary care physician, but with the option to receive care from hospitals or physicians that aren't on the plan without the need for referrals. If the insured chooses a physician or hospital outside the plan, the insured must pay a portion of the cost.
What are the criteria that need to be met in order to be considered eligible for Medicare?
• Age 65 years or older • U.S. citizenship or permanent residence • At least 10 years of Medicare-covered employment for individual or spouse • End-stage renal disease (or permanent kidney failure that requires dialysis or transplantation) • Received disability benefits under Social Security or Railroad Retirement (that is, benefits for railroad workers and their families) for 24 months
What are the characteristics of a Health Maintenance Organization (HMO)?
• All care is directed through the primary care physician or another single health care worker. • Reimbursement is made on a capitated basis( a fixed payment per patient per month). • Services outside the primary care physician's specialty must be provided by another HMO network provider.
What advantages were created after Integrated Delivery Systems (IDSs) were developed?
• Allowed providers increased negotiating ability with managed care organizations to create savings through operating efficiencies. • Increased buying power because of their expanded size. • Allowed them to make large purchases at discounted prices, therefore saving money.
What benefits are included in TRICARE?
• Authorized medical visits and prescriptions that don't require any deductibles, premiums, or copays • Preventive care • First-priority treatment at all military treatment facilities
What are the 2 Medicaid eligibility groups?
• Categorically needy eligibility means that the person and/or dependents fall into one of the categories outlined by the program and are therefore eligible to receive Medicaid coverage. • Medically needy means that persons would be eligible for Medicaid because they have high medical expenses, except that their income and/or resources are above the eligibility level set by their state. In these cases, specific medical needs make them eligible for Medicaid.
What legislative changes did the Balanced Budget Act make to Medicare and Medicaid?
• Established a Part C of the Medicare program to create new managed care and other health plan choices for beneficiaries. • New payment systems for Medicare services to improve accuracy and reduce health care spending • Expanded preventive-care benefits • Establishment of a new State Children's Health Insurance Program (SCHIP) • New eligibility options for Medicaid • Expanded assistance for low-income Medicare beneficiaries • New quality standards for Medicaid managed-care programs
What are the advantages of PPOs?
• Fixed Costs • Freedom of Choice for Patient
What are the advantages of POS plans?
• Greater Flexibility • Greater Range of Choices
What are the 4 different types of HMO plans?
• Group Model [HMO contracts with a multispecialty group to provide services.] • Independent/Individual Practice Associations (IPA) [HMO contracts with an organized group of individual physicians to provide services.] • Network Model [HMO contracts with two or more multispecialty groups to provide services.] • Staff Model [HMO employs physicians and health care workers directly to provide services.]
What are the core set of values advocated by the NCQA?
• Improving health care. • Providing accountability in health care. • Empowering customers by providing information. • Providing excellence in customer service.
What are 3 reasons people without health insurance are reluctant when it comes to recieving medical attention?
• Medicare/Medicaid financial restraints on reimbursement have resulted in many private hospitals no longer offering free (or charitable) health care. • Public hospitals that do provide charitable health care experience increased strain such as overcrowding and long waits. This further contributes to the uninsured population's reluctance to seek medical care. • Uninsured individuals delay receiving treatment as long as possible, increasing costs associated with prolonged health care services once they do enter a health care facility.
What are the disadvantages of HMOs?
• Need to Choose One Primary Care Physician to Direct All Services • Need for Approval Before Hospitalization or Specialty Care •Possibility of Delay in Receiving Payment When the Insured Person Receives Care Outside of the Designated Geographic Area
What are the advantages of HMOs?
• Predictable Costs • Broader and More Routine Coverage • No Claim Forms to Complete and Submit for Reimbursement
What are the 2 different types of commercial insurance available?
• Private, or individual, insurance provides health care coverage for the policyholder and the policyholder's family. • Employer-based, or group, insurance provides coverage to a group of people (such as employees).
What are the responsibilities of an insurer?
• Reviewing applications submitted for insurance coverage • Deciding whether to accept or reject all or part of the coverage requested • Fixing the terms of coverage
