hhs ch 9

out-of-pocket payments / cost sharing

-from patients who pay entirely or partially for services rendered

health insurance

-indemnity plans or MCOs

-helps pay for medical expenses 

MCOs (managed care organizations)

-type of health plan that manages healthcare services to control cost & maintain quality

HMOs (health maintenance organzation)

-type of managed care health insurance plan that provides care through a specific network of doctors, hospitals, & other providers

medicaid

-joint federal & state program that provides free or low-cost health coverage for low-income individuals, families, children, the elderly, & disabled

consumer-driven health plans (CDHPs) 

-combines a high-deductible health plan with a tax-advantaged savings account to give members more control and incentive to manage their healthcare costs

health reimbursement accounts (HRAs)

-an employer-funded plan that allows employees to be reimbursed tax-free for qualified medical expenses

diagnosis-related groups (DRGs)

-established to provide directions for treatment

group insurance

-a large group of individuals will purchase insurance through their employer, & the risk is spread among those paying individuals

individual private health insurance

-the risk is determined by the individuals health, premiums, deductibles & copayments are higher for this insurance 

self-funded / self-insurance programs

-health insurance programs that are implemented & controlled by the company itself 

voluntary health insurance (VHI)

-type of private health insurance that is provided by nonprofit and for-profit health plans

social insurance

-provided by the government at all levels federal, state & local

public welfare insurance

-based on financial need

ex → medicaid

health savings account (HSAs)

-tax-advantaged account that allows individuals enrolled in a high-deductible health plan to save & pay for qualified medical expenses

fee for service (FFS) / prepayment

-provide the basis for all health insurance coverage

copayments

-payments that patients must pay at the time they receive their services 

coinsurance

-type of copayment where the patient pays a percentage of the cost of the services 

deductibles

-payments that are required prior to the insurance  paying for services rendered in a ffs plan

Comprehensive health insurance policies

-provide benefits like outpatient & inpatient services, surgery, laboratory testing, medical equipment purchases

services → mental health, rehabilitation & prescription medications

major medical policies

-reimburse hospital services, such as surgeries
and expenses related to any hospitalization

-has a limit on hospital stays

Catastrophic health insurance policies

-cover unusual illnesses with a high deductible &  have lifetime reimbursement caps

disease-specific policies

-insurance policies that provide supplemental insurance coverage for medicare patients

indemnity plans or fee-for-service plans

-which have contracts between a beneficiary and a health plan but there is no contract between the health plan and providers

managed care plans

-combine health services & health insurance functions to reduce administrative costs

personal care accounts

-type of HRA where an employer contributes money to an account for employees to pay for qualified medical expenses not covered by insurance

flexible spending accounts (FSAs)

-provide employees with the option of setting aside pretax income to pay for out-of-pocket medical expenses 

medical savings accounts (MSAs)

-allows workers employed in firms with 50 or fewer employees, and who have high-deductible health insurance plans to set aside pretax $ to be used for healthcare premiums & non-reimbursed healthcare expenses

reinsurance

-a company will purchase reinsurance from another insurance company to protect itself from any losses

stop-loss measure

that limits the amount the company will pay for claims

managed care

-refers to the cost management of healthcare services utilization by controlling who the consumer sees and how much the service costs

Staff model

hires providers to work at a
physical location

group model

-Negotiates with a group of
physicians exclusively to perform services.
This was the first type of HMO model
introduced by Kaiser Permanente

Network model

-Similar to the group model, but providers may see other patients who are not members of the HMO

Independent practice associations
(IPAs)

-A group of physicians who are in
private practice to see MCO members at a
prepaid rate per visit

Preferred Provider Organizations (PPOs)

-these providers agree to a relative value-based fee schedule or a discounted fee to see members

-Do not have a gatekeeper like the HMO

-Do not have a copay but do have a
deductible

Exclusive provider organizations
(EPOs)

-Similar to PPOs but they restrict
members to the list of preferred or
exclusive providers members can use

Physician hospital organizations
(PHOs)

-Physician hospitals, surgical
centers, & other medical providers that
contract with a managed care plan to
provide health services

capitation policy / per member per month policy

the provider is paid a fixed
monthly amount per employee, which is often
called a PMPM payment

Discounted fees

-type of fee for service
but are discounted based on a fee schedule

Salaries

-the third method of payment. In
this instance, the provider is actually an
employer of the MCO

affordable care act (ACA) / Obamacare

-improve the accessibility & quality of the U.S healthcare system

restriction on provider choice

-Members of an MCO often have restrictions on their choice for a provider

gatekeeper

-A gatekeeper is a primary care provider who controls a patient's access to other medical services such as specialists

Utilization review

--evaluates the appropriateness of the types of services provided

Prospective utilization review

-is implemented before the service is performed by having the procedure authorized by the MCO based on clinical guidelines

Concurrent utilization reviews

-Decisions that are made during the actual course of service, such as length of inpatient stay or additional surgery

Retrospective utilization review

-Evaluation of services once the services
have been provided

-occur to assess treatment patterns of certain
diseases

summary of benefit & coverage

-which offers consumers the opportunity to easily compare health insurance plans

health insurance marketplaces

-run by the federal or state governments

-are central locations for healthcare consumers to purchase health insurance coverage

Medicare cost plans

-reimburse the MCOs on a
preset monthly basis per enrollee based on a
forecasted budget

The National Committee on Quality Assurance
(NCQA)

-established in 1990 to monitor
health plans and improve healthcare quality

The Health Plan Employer Data and Information Set (HEDIS)

-established by the NCQA in
1989

-used by nearly 100% of all health plans
to measure service and quality of care

Accreditation Association for
Ambulatory Health Care (AAAHC)

-ensure high-quality patient care by setting standards & accrediting organizations that meet them through a peer-based, educational survey process

silent PPOs

-unauthorized third parties outside the contract between the MCO and the physician that gain access to the MCO discount rates

samaritan Ministries

-Ted Pittenger, the founder of
Samaritan Ministries, joined a healthcare sharing ministry & was inspired by the potential for this non insurance option to provide Biblical, affordable health care for the Christian community

cms innovation center

created & funded demonstration projects that focus on this type of care model

Consumer Operated and Oriented Plans
(CO-OPs)

-member-run health organizations, and must be consumer focused with profits targeted to lowering premiums and
improving benefits, were established

medicare part A

-primarily financed from payroll taxes & is considered hospital Insurance 

medicare part B

supplemental health plan to cover physician services

medicare part C

-considered a managed care model

-covers all services in A & B

medicare part D

-produced largest changes to medicare

-purpose was to provide seniors with relief from high prescription costs

children’s health insurance program (CHIP)

-initiated in response to the number of children who are uninsured in the U.S

-funded jointly by the federal government & states through a formula

risk plans

pay a premium per member that is based on the members county of residence 

Program of All-Inclusive Care for the
Elderly (PACE)

-a comprehensive healthcare
delivery system funded by Medicare and
Medicaid

workers’ compensation

-protects both the employer & employee if a job-related injury or illness occurs or the employer is financially  liable for employees who become injured or ill as a result of working conditions

- a state-administered program

TRICARE

-developed to respond to the growing needs of retired members

-combines the healthcare resources of
the uniformed services with networks of civilian
healthcare professionals, institutions, pharmacies, and suppliers to provide access to high-quality healthcare services while maintaining the capability to support military operations

Veterans Health Administration

-America’s largest integrated healthcare
system

-The systems serves 9 million enrolled
veterans each year

Reimbursement Methods of Private
Health Insurance (UCR)

-based on community & state surveys of provider charges 

-defined as the professional charge for
service/product performed or provided by a
professional or facility

Prospective Reimbursement

-the most common type of reimbursement is a
service benefit plan

-The employer has a contract with a benefit plan and pays a premium for each of its employees

retrospective reimbursement

-determines the amount of reimbursement after the delivery of services & provides little financial risk to providers

Indian health service

-principal federal healthcare provider & health advocate for Indian people

service benefit plan

-employer has a contract with a benefit plan & pays a premium for each of its employees

Ambulatory patient groups

-a system of codes that explain the
number of services and visits.

Patient-Driven Patient Model

-type of prospective payment system for skilled nursing facilities, used by Medicare, provides for a per diem based on the clinical severity of patients

value based reimbursement

-a healthcare model that aims to incentivize providers to deliver high quality patient centered care