Chpt 6 Medical Benefits in the United States

Question 1

U.S. Medical benefits, covered facilities

Answer 1

1. Hospital inpatient services
2. Emergency room limitations avoid excess utilization
3. Outpatient surgery
4. Psychiatric admissions and alcohol and drug treatment
5. Skilled nursing facility (SNF)
6. HHC limited to services performed in lieu of other treatment

Question 2

U.S. Medical covered professional services

Answer 2

1. Limited to licensed or board certified providers
2. May exclude certain provider types such as dentists, chiropractors
3. Includes surgeries on an impatient, outpatient, and office basis
4. Physician services include office visits, home visits, hospital visits, emergency room visits, and preventive care
5. Additional services include obstetrician or a gynecologist, outpatient psychiatric, outpatient alcohol and drug, physical therapy, immunization and injections
6. Some plans have a gate-keeper requirement

Question 3

U.S. Medical other covered services

Answer 3

1. Diagnostic, X-Ray and lab
2. Prescription drugs
3. Appliances and durable medical equipment
4. Ambulance
5. Private duty nursing, nursing help lines
6. Wellness benefits
7. Disease management

Question 4

Provision for cost sharing

Answer 4

1. Deductible
   
   1. 1 amount of services paid by individual before plan pays
   2. 2 May exempt preventive care services
   3. 3 may apply to specific services such as hospital admissions
   4. 4 Family contract deductibles
2. Coinsurance
   
   2. 1 Percentage of services paid by the insurer after the deductible
   3. 2 Coinsurance level can vary for difference services
3. Copays
   
   3. 1 Fixed dollar amount paid each time covered service takes place
   4. 2 Vary significantly by service type to impact utilization
4. UCR maximums
   
   4. 1 Reflect the lowest of a providers usual charges, charges customary in that geographic region and a level reasonable in relationship to the services provided
5. Varying cost sharing to encourage use of certain providers
6. Annual maximums and lifetime maximums
7. Daily limit maximums and number of day limits

Question 5

Provider risk sharing and advantages and disadvantages

Answer 5

1. Discounts for billed charges
   
   1. 1 Simplest form of provider cost sharing
   2. 2 Providers no incentives for utilization modifications
2. Few schedules or fee maximums
   
   2. 1 Fails to affect utilization
   3. 2 Adv. over a discount from billed charges: provide unable to adjust billed charges
3. Per diem contracts
   
   3. 1 No incentive to encourage outpatient use or reduced lengths of stay
4. Reimbursement based on DRG (diagnosis related groups)
   
   4. 1 utilization incentives regarding charges during a hospital admission, but limited incentives for number of admissions
5. Bonus pools
   
   5. 1 if bonus not a significant proportion of income, provider maximizes income by increasing utilization
   6. 2 May be difficult to enroll providers
   7. 3 ethical questions when a provider is given financial incentive not to provide care
6. Capitation
   
   6. 1 May reduce costs and provide utilization incentives
   7. 2 Raises ethical questions mentioned above in bonus pools

Question 6

Other Medical Plan Provisions

Answer 6

1. Exclusions
2. Mandated benefits
3. Coordination of benefits (COB)
4. Subrogation clause
5. Pre existing exclusion clause
   
   5. 1 Health care reform essentially eliminated this
6. Consolidated Omnibus Reconciliation Act (COBRA)
7. Conversion privilege