US Medical Benefits Flashcards
US Medical Benefits
Service vs. Indemnity Benefits
- Service = provides medical services directly
- Indemnity = Plan pays for expenses incurred up to predefined level
US Medical Benefits
Dimensions of Medical Plans
- Covered Services and Conditions
- Cost-Sharing
- Provider Relationships
US Medical Benefits
ACA Impact on Covered Services and Limitations
- Standardized preventive services
- Prohibited lifetime/annual maximums
- Limits OOP maximum
- Created Essential Health Benefits
US Medical Benefits
Covered Facilities
- Hospital IP
- ER
- OP Surgery
- Psychiatric admissions
- SNF
- HH
US Medical Benefits
Covered Professional Services
Limited to credentialed providers
- Surgeons
- Physicians
- Specialists
US Medical Benefits
Other Covered Services
- Diagnostic
- Lab
- Pharmacy
- DME
- Disease Management
- Wellness benefits
US Medical Benefits
Purpose of Cost-Sharing
- Control Utilization (Awareness of cost lowers utl)
- Control Cost (lowers premium)
- Control of Risk to Insurer (truly insurable risk)
US Medical Benefits
Types of Cost-Sharing (List and Define)
- Deductible = Services paid by insured before plan pays
- Coinsurance = % of services paid by insurer after deductible
- Copay = fixed amount paid each time service occurs
- UCR Maximum = Usual, Customary, and Reasonable charge
- Daily Limit Maximums = Used in SNF, HH
- Reference-Based Pricing = Benchmark reference as the max plan will pay for service
US Medical Benefits
Purpose of Provider Risk-Sharing
- Reduce costs
- Incentivize providers to control utilization
US Medical Benefits
Types of Provider Risk Sharing
- Discounts for Billed Charges
- Fee Schedules
- Per Diem Contracts
- DRG reimbursement
- Bonus Pools
- Capitation
- Integrated Delivery System
US Medical Benefits
Discounts for Billed Charges (Pros, Cons)
- Pro = Simple
- Con = No incentive for utilization modifications
US Medical Benefits
Fee Schedule (Pros, Cons)
- Pro = Simply reduces cost
- Con = Fails to impact utilization
US Medical Benefits
Per Diem Contract ( Cons)
- Con = No incentive to encourage OP use or reduced LOS
US Medical Benefits
DRG Reimbursement (Pros, Cons)
- Pro = Utilization incentives for charges during admission
- Con = No incentives for the # of admissions
US Medical Benefits
Bonus Pools (Pros, Cons)
- Pro = Incentive to control utilization
- Cons
- Difficult to enroll providers
- Ethical question of financial incentive to not provide care
- Providers can game system
US Medical Benefits
Capitation (Pros, Cons)
- Pros
- Reduces costs
- Utilization incentive for provider
- Con
- Ethical question of financial incentive to not provide care
US Medical Benefits
Integrated Delivery System
Insurer owns or employs providers
US Medical Benefits
Narrow vs. Broad Network
-
Narrow
- Lower Cost product
- Less freedom for Insured to choose
-
Broad
- Higher Cost product
- More freedom for Insured to choose
US Medical Benefits
Exclusions
- Not medically necessary
- Experimental, cosmetic services
- Transplants
- War/Work-related injury services
- Charges from provide related to patient
US Medical Benefits
Subrogation Clause
Carrier can seek payment for medical charges from party who caused injury
US Medical Benefits
COBRA
Requires ERs to offer continued coverage for 18-36 months beyond a person’s termination date
US Medical Benefits
Types of Managed Care Plans (List from Most to Least Restrictive and Define)
- HMO = tightest network + PCP gatekeeper
- EPO = regulated as insurance contract
- POS = Can seek care outside of network for higher cost-sharing
- PPO = Use preferred or non-preferred provider
