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Design & Pricing > Types of Insurers > Flashcards

Types of Insurers Flashcards

1
Q

Types of Insurers

List the types of health insurers and MCOs

A
  • Indemnity Insurance
  • Service Plans
  • Managed Indemnity
  • PPO
  • EPO
  • POS
  • HMO
  • CDHP
  • Third-Party Administrator
  • CO-OP
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2
Q

Types of Insurers

Indemnity Insurance

A

Reimburse beneficiary for financial cost associated with health care

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3
Q

Types of Insurers

Indemnity Insurance

Advantages and Disadvantages

A
  • Adv = Simple
  • Disadv = few controls to manage cost
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4
Q

Types of Insurers

Service Plans

A

Similar to indemnity insurance, but with MC elements

  • Plan contracts directly with providers
  • No balance billing
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5
Q

Types of Insurers

Managed Indemnity

A

MC overlays to combine with traditional indemnity insurance or service plans

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6
Q

Types of Insurers

Managed Indemnity

MC Overlays

A
  • UM
  • Large care management
  • Disease management
  • Rental networks
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7
Q

Types of Insurers

PPO

A

Entities that contract with network of “preferred” providers with cost-sharing incentives

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8
Q

Types of Insurers

How are EPOs similar/dissimilar to PPOs and HMOs?

A
  • Like PPO, but limits coverage only to in-network
  • Doesn’t require PCP gatekeeper like HMO
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9
Q

Types of Insurers

POS Plans

A

Combines HMO with indemnity type coverage for care received outside of HMO

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10
Q

Types of Insurers

HMO Definition

A

Responsible for financial aspects of coverage and delivery system to provide covered services

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11
Q

Types of Insurers

Things that Differentiate HMOs from Health Insurers

A
  • 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
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12
Q

Types of Insurers

Open-Panel HMOs (Define, Examples)

A
  • Contract with private physicians to provide care
  • Examples: IPA, Direct Contract
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13
Q

Types of Insurers

Closed-Panel HMOs (Define, Examples)

A
  • Provide care through either medical group associated with HMO or physicians employed by HMO
  • Examples: Group model, Staff model
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14
Q

Types of Insurers

Open-Panel HMO Advantages/Disadvantages

A
  • Advantages
    • Easily marketed
    • More convenient locations
    • Easier and less costly to set up and maintain
  • Disadvantages
    • Little ability to manage care
    • Higher premiums
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15
Q

Types of Insurers

Closed-Panel HMO Advantages/Disadvantages

A
  • 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
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16
Q

Types of Insurers

Types of HMOs

A
  • IPA
  • Direct Contract Model
  • Group Model
  • Staff Model
  • True Network Model
  • Mixed Model HMOs
  • Open-Access HMOs
17
Q

Types of Insurers

Types of HMOs

Independent Practice Association (IPA)

A

HMO contracts with association of physicians (IPA) to provide service to members

18
Q

Types of Insurers

Types of HMOs

Direct Contract Model

A

HMO contracts directly with independent physicians or medical groups

  • HMO does credentialing, network management, and UM
19
Q

Types of Insurers

Types of HMOs

Group Model

A

HMO contracts with multi-specialty medical group practice to provide all physician services to HMO members

20
Q

Types of Insurers

Types of HMOs

Staff Model

A

Physicians are employed by HMO

21
Q

Types of Insurers

Types of HMOs

True Network Model

A

HMO contracts with more than 1 medical group or physician organization

22
Q

Types of Insurers

Types of HMOs

Mixed Network Model

A

Mix of different model types

  • Most common = closed-panel MCO adds open-panel components to their health plan
23
Q

Types of Insurers

Types of HMOs

Open-Access HMOs

A

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)
24
Q

Types of Insurers

Consumer-Directed Health Plan (CDHP)

A

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
25
Q

Types of Insurers

Consumer-Directed Health Plan (CDHP)

2 Forms

A
  • ER-Based = Health payment account (HRA)
  • Individual-Based = Health savings account (HSA)
26
Q

Types of Insurers

Third Party Administrators

A

Administers benefits for self-funded ER group

  • Enrollment and claims processing
  • UM
27
Q

Types of Insurers

Consumer-Operated and Oriented Plans (CO-OP)

A

Offers coverage to small groups and individuals through state exchanges

28
Q

Types of Insurers

Types of Integrated Health Care delivery Systems

A
  • 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
29
Q

Types of Insurers

Integrated Health Care Delivery Systems

A

Providers coming together to mange health care and contract with HMOs/PPOs/Insurers

30
Q

Types of Insurers

Physician Practice Management Companies (PPMC)

A
  • Publicly traded companies
  • Most failed because of the focus on needing to report positive earnings
31
Q

Types of Insurers

Group Practice Without Walls (GPWW)

A

Physicians agree to aggregate their practices into single legal entity, but continue to practice in their independent locations

32
Q

Types of Insurers

Physician-Hospital Organizations (PHO)

A

Entity that allows hospital and its physicians to negotiate with payers

  • PHO participants develop contract terms and use them to negotiate with payers
33
Q

Types of Insurers

Management Services Organizations (MSO)

A

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
34
Q

Types of Insurers

Foundation Model

A

Hospital creates a not-for-profit foundation, purchases physicians’ practices, and puts those practices into the foundation

35
Q

Types of Insurers

Provider-Sponsored Organizations (PSO)

A

Authorized to contract directly with Medicare on an at-risk basis for all medical services, bypassing existing Medicare HMOs

  • Resulted in deep financial losses
36
Q

Types of Insurers

Hospitals with Employed Physicians

A

Hospitals employing both PCPs and specialists to increase hospital’s negotiating leverage

37
Q

Types of Insurers

ACO must be formed for the purpose of:

A
  • Receiving and distributing shared savings
  • Repaying shared losses to CMS
  • Establishing, reporting, and ensuring provider compliance with healthcare quality criteria
38
Q

Types of Insurers

Principles of PCMH

A
  • 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
39
Q

Types of Insurers

PCMH vs. Gatekeeper PCP Model HMOs

A
  • PCMH recognizes care team aligned around PCP (Like closed-panel HMOs)
  • PCMH focuses on quality and improvement aspects of PCPs role (Like HMOs)

Design & Pricing (64 decks)

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