Types of Insurers Flashcards
Types of Insurers
List the types of health insurers and MCOs
- Indemnity Insurance
- Service Plans
- Managed Indemnity
- PPO
- EPO
- POS
- HMO
- CDHP
- Third-Party Administrator
- CO-OP
Types of Insurers
Indemnity Insurance
Reimburse beneficiary for financial cost associated with health care
Types of Insurers
Indemnity Insurance
Advantages and Disadvantages
- Adv = Simple
- Disadv = few controls to manage cost
Types of Insurers
Service Plans
Similar to indemnity insurance, but with MC elements
- Plan contracts directly with providers
- No balance billing
Types of Insurers
Managed Indemnity
MC overlays to combine with traditional indemnity insurance or service plans
Types of Insurers
Managed Indemnity
MC Overlays
- UM
- Large care management
- Disease management
- Rental networks
Types of Insurers
PPO
Entities that contract with network of “preferred” providers with cost-sharing incentives
Types of Insurers
How are EPOs similar/dissimilar to PPOs and HMOs?
- Like PPO, but limits coverage only to in-network
- Doesn’t require PCP gatekeeper like HMO
Types of Insurers
POS Plans
Combines HMO with indemnity type coverage for care received outside of HMO
Types of Insurers
HMO Definition
Responsible for financial aspects of coverage and delivery system to provide covered services
Types of Insurers
Things that Differentiate HMOs from Health Insurers
- Licensed by states under different laws than insurers
- Must provide adequate access to providers within its service area
- No balance billing clauses
- Direct access to PCPs
- Written policies for UM/QM and credentialing
Types of Insurers
Open-Panel HMOs (Define, Examples)
- Contract with private physicians to provide care
- Examples: IPA, Direct Contract
Types of Insurers
Closed-Panel HMOs (Define, Examples)
- Provide care through either medical group associated with HMO or physicians employed by HMO
- Examples: Group model, Staff model
Types of Insurers
Open-Panel HMO Advantages/Disadvantages
- Advantages
- Easily marketed
- More convenient locations
- Easier and less costly to set up and maintain
- Disadvantages
- Little ability to manage care
- Higher premiums
Types of Insurers
Closed-Panel HMO Advantages/Disadvantages
- Advantages
- Closely manage medical care
- “One stop shopping” for members
- Disadvantages
- Harder to market
- Not convenient locations
- More complex and costly to set up and maintain
Types of Insurers
Types of HMOs
- IPA
- Direct Contract Model
- Group Model
- Staff Model
- True Network Model
- Mixed Model HMOs
- Open-Access HMOs
Types of Insurers
Types of HMOs
Independent Practice Association (IPA)
HMO contracts with association of physicians (IPA) to provide service to members
Types of Insurers
Types of HMOs
Direct Contract Model
HMO contracts directly with independent physicians or medical groups
- HMO does credentialing, network management, and UM
Types of Insurers
Types of HMOs
Group Model
HMO contracts with multi-specialty medical group practice to provide all physician services to HMO members
Types of Insurers
Types of HMOs
Staff Model
Physicians are employed by HMO
Types of Insurers
Types of HMOs
True Network Model
HMO contracts with more than 1 medical group or physician organization
Types of Insurers
Types of HMOs
Mixed Network Model
Mix of different model types
- Most common = closed-panel MCO adds open-panel components to their health plan
Types of Insurers
Types of HMOs
Open-Access HMOs
Hybrid of POS and EPO
- Member selects PCP and gets best benefits using HMO, but can access specialty care directly with less coverage (POS)
- Only services provided by in-network providers are covered (EPO)
Types of Insurers
Consumer-Directed Health Plan (CDHP)
Combine high-deductible health plan (HDHP) with pretax savings account
- Health costs are first paid from pretax account and then additional costs up to deductible are paid OOP
Types of Insurers
Consumer-Directed Health Plan (CDHP)
2 Forms
- ER-Based = Health payment account (HRA)
- Individual-Based = Health savings account (HSA)
Types of Insurers
Third Party Administrators
Administers benefits for self-funded ER group
- Enrollment and claims processing
- UM
Types of Insurers
Consumer-Operated and Oriented Plans (CO-OP)
Offers coverage to small groups and individuals through state exchanges
Types of Insurers
Types of Integrated Health Care delivery Systems
- IPA
- Physician Practice Management Companies (PPMC)
- Group Practice without Walls (GPWW)
- Physician-Hospital Organizations (PHO)
- Management Services Organizations (MSO)
- Foundation Model
- Provider-Sponsored Organizations (PSO)
- Hospitals with Employed Physicians
Types of Insurers
Integrated Health Care Delivery Systems
Providers coming together to mange health care and contract with HMOs/PPOs/Insurers
Types of Insurers
Physician Practice Management Companies (PPMC)
- Publicly traded companies
- Most failed because of the focus on needing to report positive earnings
Types of Insurers
Group Practice Without Walls (GPWW)
Physicians agree to aggregate their practices into single legal entity, but continue to practice in their independent locations
Types of Insurers
Physician-Hospital Organizations (PHO)
Entity that allows hospital and its physicians to negotiate with payers
- PHO participants develop contract terms and use them to negotiate with payers
Types of Insurers
Management Services Organizations (MSO)
Evolution of PHO into an entity that provides more services to support physicians
- Physician remains an independent private practitioner
- MSO provides support services to member physicians
Types of Insurers
Foundation Model
Hospital creates a not-for-profit foundation, purchases physicians’ practices, and puts those practices into the foundation
Types of Insurers
Provider-Sponsored Organizations (PSO)
Authorized to contract directly with Medicare on an at-risk basis for all medical services, bypassing existing Medicare HMOs
- Resulted in deep financial losses
Types of Insurers
Hospitals with Employed Physicians
Hospitals employing both PCPs and specialists to increase hospital’s negotiating leverage
Types of Insurers
ACO must be formed for the purpose of:
- Receiving and distributing shared savings
- Repaying shared losses to CMS
- Establishing, reporting, and ensuring provider compliance with healthcare quality criteria
Types of Insurers
Principles of PCMH
- Ongoing relationship with personal physician
- Personal physicians provide/arrange all health care with team
- Quality and safety are enhanced by evidence-based medicine with continuous quality improvement and patient engagement
- Enhanced access to care through open scheduling, expanded hours, and better communication
Types of Insurers
PCMH vs. Gatekeeper PCP Model HMOs
- PCMH recognizes care team aligned around PCP (Like closed-panel HMOs)
- PCMH focuses on quality and improvement aspects of PCPs role (Like HMOs)
