H4: Medical Expense Insurance (Section II)

Service type Plans

Managed Care

Gatekeeper System

Preventive Care (Wellness Benefits)

Case Management

Capitation

Managed care

Health Maintenance Organizations (HMOs)

HMO

HMOs provide both

HMO's are NOT required by law to cover prescription drugs but they usually do

Staff Model HMO

Group Model HMO

IPA HMO

Independent Practice Association

Dual Choice Provision

Blue Cross/Blue Shield

Service-Benefit Concept

Pre-paid Plan

PPOs

PPO Providers paid on a Fee-for-Service basis

EPO Network

POS Network

Consumer Driven Health Plan (CDHP)

High Deductible Health Plan (HDHP)

Health Savings Account (HSA)

Medical Savings Account (MSA)
AKA Archer MSA

Eligibility for MSA

MSA Contributions

Health Reimbursement Account (HRA)

HRA

Flexible Spending Account (FSA)

Service providers pay the provider directly

HMO provides both healthcare services and healthcare coverage

HMOs have a set list of providers, and a gatekeeper (refers insureds to specialist)

HMOs have a set list of providers, and a gatekeeper (refers insureds to specialist)

HMOs used gatekeeper system that refers patients to specialists when needed.

HMO's are not required to cover Prescription Drugs

HMOs try to minimize the use of specialty physicians

capitation

Independent Practice Association (IPA)

HMO pays the care giver directly

Employer must provide DUAL CHOICE if 25+ employees

HMOs can be owned by business organizations and commercial insurers

Blue Cross & Blue Shield = PREPAID PLANS

Blue Cross= hospital service

Blue Shield= physician service

EPO: MUST use network or you will pay fee on your own.