Tiered Network Health Plans Flashcards
1
Q
Tiered Network Health Plans
Advantages
A
-
TNHP Design Savings
- Consumers = lower cost-sharing
- Health Plans = save with negotiated discounts
- Better Health
-
Significant Cost Differential
- Increases potential of driving plan members to in-network providers
2
Q
Tiered Network Health Plans
Disadvantages
A
-
Markets with Limited Provider Competition
- Decreased comp = reduces leverage of TNHP to obtain high-value providers
-
Service vs. Product
- Hard to compare people-driven care quality vs. product-driven drug quality
-
Negligible Cost Differential
- Small discounts = don’t increase likelihood of switching
- State Requirements
3
Q
Tiered Network Health Plans
Categories of Providers within TNHP
A
- In-Network
- Preferred
- Non-Preferred
- Out-of-Network
4
Q
Tiered Network Health Plans
TNHP Savings Formula
A
TNHP Savings = N% [M% + Shift (P% - M%)]
- N = % of claims attributed to non-preferred in-network providers
- M = Member liability differential = impact of member liability on INN non-preferred providers
- Shift = % of INN non-preferred users moving to INN preferred network
- P = Cost Differential between Tier Providers
5
Q
Tiered Network Health Plans
TNHP Savings Formula: Shift
A
- Shift = % of INN non-preferred users moving to INN preferred network
6
Q
Tiered Network Health Plans
TNHP Savings Formula: M
A
- M = Member liability differential = impact of member liability on INN non-preferred providers
7
Q
Tiered Network Health Plans
TNHP Savings Formula: N
A
- N = % of claims attributed to non-preferred in-network providers
8
Q
Tiered Network Health Plans
TNHP Savings Formula: P
A
- P = Cost Differential between Tier Providers
