Health Plans

Anlagen:

• Health Plans - Concepts

1. MCP

   Anmerkungen:

   • Manage Care Plans are an approach/variety of models to manage quality and cost in medical care. IOW a system that integrates - Financing & Delivery of medical care - w/ providers.   
   1. MPP

      Anlagen:

      • MPPs - Comparison
      1. PPO

         Anmerkungen:

         • Preferred Provider Org:  Lies between an HMO (by Mo. premiums) and as a Fee-For-Service (by paying only for provider’s services). Most popular in the individual & family market. Pros – No “referral” needed/freedomCons – Expensive outside-Network providers.  
      2. HMO

         Anmerkungen:

         • Health Maintenance Org: insurers & providers get best deals for insurer. Members make use only of in-Network providers else the member is financially responsible.  Pro – Great Savings / Avoid dealing w/ claims Cons – “Referral” needed. 
      3. POS

         Anmerkungen:

         • Point-Of-Service: Blend of HMO & PPO. Members decide providers after use of service.  Pro – More freedom Cons – PCP & “referral” needed. 
      4. Indeminity

         Anmerkungen:

         • Indemnity Insurance(Traditional Fee for Service Plan): Reimburses medical expense. Most of the time includes a deductible. After deductible met insurers pay claims at a set percentage of UCR rate.
   2. Provider's Reinbursement
      1. Free-Of-Service

         Anmerkungen:

         • Is a payment model where services are unbundled and paid for separately.
      2. Capitation

         Anmerkungen:

         • “pre-payment” / Physicians are paid a fixed amount per Mo.
      3. Bonuses Witholds

         Anmerkungen:

         • if premiums from enrollees are less than health plan payments to physicians then a percentage of fee-of-service or capitation from ea. service is retained and later returned as a bonus at the end of the year.   
      4. Medicare DRG's

         Anmerkungen:

         • Diagnosis Related Group: “Reward System” / flat rate per case for inpatient hospital care; if efficiency improved then they receive an incentive.
2. Employee Health Plans
   1. Fully- Insured/Funded

      Anmerkungen:

      • Employer assumes financial responsabilities
   2. Self- Insured/Funded

      Anmerkungen:

      • Employer pays for claims out-of-pocket. Concepts within self-Insured
3. Government Health Plans
   1. VA

      Anmerkungen:

      • Veterans Administration:  Provide eligible vets health services as “needed” (care or service that will promote, preserve, and restore health)
   2. HHS

      Anmerkungen:

      • U.S. Department of Health & Human Services (HHS) enhances and protects the health and well-being of all Americans. It provides effective health and human services and fostering advances in medicine, public health, and social services.
      1. CMS
         1. Medicare

            Anmerkungen:

            • Is health insurance for people 65 yrs. of US citizenship, etc... < 65 yrs.If it has a disability if ESRD (End-Stage Renal Disease).

            Anlagen:

            • Gov. Health Plans - Medicare
         2. CMCS

            Anmerkungen:

            • The Center for Medicaid and CHIP Services (CMCS) serves as the focal point for all national program policies and operations related to Medicaid
            1. Medicaid

               Anmerkungen:

               • Federal and State programs that helps w/ medical costs for some people w/ low income & limited resources.  Pros – It covers services that Medicare doesn’t.  Cons – Rules change vary by state.  
            2. CHIP

               Anmerkungen:

               • Previously nown as State Children’s Health Insurance Program: Partnership between Federal & State Governments to mainly children who don’t qualify for Medicaid and can’t afford a private insurer.  Requirements: < 19 yrs. old
            3. BHP

               Anmerkungen:

               • Basic Health Program: was enacted by the Affordable Care Act and provides states the option to establish health benefits cover programs for low-income residents who would otherwise be eligible to purchase coverage through the Health Insurance Marketplace, providing affordable coverage and better continuity of care for people whose income fluctuates above and below Medicaid and CHIP levels.
4. CDHP

   Anmerkungen:

   • Consumer Driven Health Plans:  is a type of medical insurance that has a higher deductible and low premium. It can be offered w/ a combination of the following accounts
   1. HDHP

      Anmerkungen:

      • High Deductible Health Plan: Health insurance plan w/ lower premiums and higher deductibles than traditional health plan. A health saving account is needed. HDHP are a form of catastrophic coverage; “freedom” depends on the health plan (HMO, POS, or PPO).
   2. Helthcare Accounts

      Anlagen:

      • CDHP - Healthcare Accounts
      1. FSA

         Anmerkungen:

         • Flexible Spending Account: Similar to HSA but w/ more “flexibility”
      2. HSA

         Anmerkungen:

         • HSA (Health Savings Account): Used only for medical care.   
      3. HRA

         Anmerkungen:

         • Health Reimbursement Account: Health benefit plan designed by your employer to reimburse you for certain eligible healthcare expenses