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
