Understanding Health Insurance – week 3

accreditation
a voluntary process that a health care facility or organization (e.g. hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law.
adverse selection
members who are sicker than the general population
Amendment to the HMO Act of 1973
allowed federally qualified HMOs to permit members to occasionally use non-HMO physicians and be partially reimbursed
cafeteria plan
is usually offered either by a single insurance plan or as a joint venture among two or more insurance carriers, provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans. It is also called a cafeteria plan or flexible benefit plan because of the different benefit plans and extra coverage options provided through the insurer or third-party administrator. Triple actions plans are intended to prevent the problem of covering members who are sicker than the general population (called adverse selection),
capitation
pre-established payments for providing health care services to enrolees over a period of time (usually 1 yr.) Physician either profits or loses money)
case management
involves the development of patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner
case manager
submits written confirmation, authorizing treatment to the provider
closed-panel HMO
health care is provided in an HMO-owned center or satellite clinic or by physicians who belong to a specially formed medical group that serves the HMO
competitive medical plan (CMP)
an HMO that meets federal eligibility requirements for a Medicare risk contract, but is not licensed as a federally qualified plan.
concurrent review
review for medical necessity of tests and procedures ordered during an inpatient hospitilization
consumer-driven health plan (CDHP)
define employer contributions and ask employees to be more responsible for health care decisions and cost-sharing
customized sub-capitation plan (CSCP)
health care expenses are funded by insurance coverage; the individual selects one of each type of provider to create a custommized network and pays the resulting customized insurance premium – each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider (sub-capitation payment)
direct contract model HMO
contracted health care services are delivered to subscribers by individual physicians in the community
discharge planning
involves arranging appropriate health care services for the discharged patient
enrollees
employees & dependents; known as beneficiaries in privable insurance plans
exclusive provider organization (EPO)
a managed care plan that provides benefits to subscribers if they receive services from network providers. A network providers is a physician or health care facility under contract to the managed care plan.
external quality review organization (EQRO)
Many states have enacted legislation requring EQROs to review health care provided by managed care organizations. The types of quality reviews performed include government oversight, patient satisfaction surveys, data collected from grievance proceudres, and reviews conducted by independent organizations. Independent organizations that perform reviews include accrediation agencies such as the National committee for Quality Assurance and Joint Commission on Accreditation of Healthcare Organizations.
federally qualified HMO
certified to provide health care services to Medicare and Medicaid enrollees as one that has applied for and met federal standards established in the HMO Act of 1973
fee-for-service
reimbruse providers for individual health care services rendered
flexible benefit plan
is usually offered either by a single insurance plan or as a joint venture among two or more insurance carriers, provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans. It is also called a cafeteria plan or flexible benefit plan because of the different benefit plans and extra coverage options provided through the insurer or third-party administrator. Triple actions plans are intended to prevent the problem of covering members who are sicker than the general population (called adverse selection),
flexible spending account (FSA)
tax exempt accounts offered by employers with any number of employees, which individuals use to pay health care bills

participants enroll in a relatively inexpensive high-deductible insurance plan, and a tax-deductible savings account is opened to cover current and future medical expenses

money deposed (and earnings) is tax-deferred, and money withdrawn to cover qualified medical expenses is tax free

money can be withdrawn for purposed other than health care expenses after payment of income tax plus a 15% penalty

unused balances “roll over” from year to year, and if an employee changes jobs, he or she can continue to use the FSA to pay for qualified health care expenses

gag clause
prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services
gatekeeper
provides essential health care services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists. Used by primary care providers.
group model HMO
contracted health care services are delivered to subscribers by participating physicians who are members of an independent multispecialty group practice. The HMO reimburses the physican group, which is then responsible for reimbursing physician members and contracted health care facilities (e.g. hospitals). The physician group can be owned or managed by the HMO, or it can simply contract with the HMO.
group practice without walls (GPWW)
establishes a contract that allows physicians to maintain their own offices and share service (e.g. appointment scheduling and billing)
health care reimbursement arrangement (HCRA)
tax exempt account used to pay for health care expenses – individual decides, in advance, how much money to deposit in HCRS (unused funds are lost)
health reimbursement arrangement (HRA)
tax exempt accounts offered by employees with more than 50 employees, which individuals use to pay health care bills
United States Treasury Department and IRS issued a tax guidance for HRAs in 2002
Must be used for qualified health care expenses, require enrollment in a high-duductible insurance policy and accumulate money for future years
If an employee changes jobs, he or she can continue to use the HRA to pay for qualified health care expenses
health savings account (HSA)
tax exempt accounts offered by employers with any number of employees, which individuals use to pay health care bills

participants enroll in a relatively inexpensive high-deductible insurance plan, and a tax-deductible savings account is opened to cover current and future medical expenses

money deposed (and earnings) is tax-deferred, and money withdrawn to cover qualified medical expenses is tax free

money can be withdrawn for purposed other than health care expenses after payment of income tax plus a 15% penalty

unused balances “roll over” from year to year, and if an employee changes jobs, he or she can continue to use the FSA to pay for qualified health care expenses

health savings security account (HSSA)
tax exempt accounts offered by employers with any number of employees, which individuals use to pay health care bills

participants enroll in a relatively inexpensive high-deductible insurance plan, and a tax-deductible savings account is opened to cover current and future medical expenses

money deposed (and earnings) is tax-deferred, and money withdrawn to cover qualified medical expenses is tax free

money can be withdrawn for purposed other than health care expenses after payment of income tax plus a 15% penalty

unused balances “roll over” from year to year, and if an employee changes jobs, he or she can continue to use the FSA to pay for qualified health care expenses

independent practice association (IPA) HMO
contracted health services are delivered to subscribers by physicians who remain in their independent office settings. The IPA is an intermediary (e.g. physician association) that negotiates the HMO contract and receives and manages the capitation payment from the HMO, so that physicians are paid on either a fee-for-service or capitation basis.
individual practice association (IPA) HMO
contracted health services are delivered to subscribers by physicians who remain in their independent office settings. The IPA is an intermediary (e.g. physician association) that negotiates the HMO contract and receives and manages the capitation payment from the HMO, so that physicians are paid on either a fee-for-service or capitation basis.
integrated delivery system (IDS)
an organization of affiliated providers’ sites (e.g. hospitals, ambulatory surgical centers, or physician groups) that offer joint health care services to subscribers. Models include physician-hospital organizations, management service organizations, group practices without walls, integrated provider organizations, and medical foundations.
integrated provider organization (IPO)
manages the delivery of health care services offered by hospitals, physicians (who are employees of IPO) and other health care organizations (e.g., an ambulatory surgery clinic and a nursing facility)
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
provides voluntary accreditation of a variety of health care organizations (e.g. hospitals, long-term care and ambulatory care facilities)
legislation
laws
managed care organization (MCO)
responsible for the health of a group of enrolles, and can be a health plan, hospital, physician group, or health system
managed health care (managed care)
developed as a way to provide affordable, comprehensive, prepaid health care services to enrollees (employees & dependents; known as beneficiaries in private insurance plans). Managed care is financed thru capitation.
management service organization (MSO)
usually owned by physicians or a hospital and provides practice management (administrative and support) services to individual practices.
mandate
laws
medical foudation
a nonprofit organization that contracts with and acquires the clinical and business assets of physican practies; the foundation is assigned a provider number and manages the practice’s business.
medical savings account (MSA)
allows individuals to withdraw tax-free funds for health care expenses that are not covered by a qualifying high-deductible health plan.
Medicare + Choice (Medicare Part C)
expanded Medicare coverage options by creating managed care plans, to include HMOs, PPOs and MSAs.
Medicare risk program
allows federally qualified HMOsd and competitive medical plans that met specified Medicare requiements to provide Medicare covered services under a risk contract
National Committee for Quality Assurance (NCQA)
reviews managed care plans and develops report cards to allow health care consumers to make informed decisions when selecting a plan.
network model HMO
contracted health care services are provided to subscribers by two or more physicians multi-specialty grou practices
network provider
a physician or health care facility under contract to the managed care plan
Office of Managed Care
facilitated innovation and completion among Medicare HMOs
open-panel HMO
Health care is provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO
physician incentive plan
requires managed care plans that contract with Medicare or Medicaid to disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval.
physician incentives
include payments made directly or indirectly to health care providers to serve as encouragement to reduce or limit services (e.g. discharge an inpatient from the hospital more quickly) so as to save money for the managed care plan.
physician-hospital organization (PHO)
owned by hospital(s) and physician groups that obtain managed care plan contracts; physicians maintain their own practices and provide health care services to plan members.
point-of-service plan (POS)
patients have freedom to use the HMO panel of providers or to self-refer to non-HMO providers
preadmission certification (PAC)
or preadmission review – review for medical necessity of inpatient care prior to the patient’s admission.
preadmission review
or PAC) – review for medical necessity of inpatient care prior to the patient’s admission.
Preferred Provider Health Care Act of 1985
eased restrictions on preferred provider organizations (PPOs) – allowed subscribers to seek health care from providers outside of the PPO
preferred provider organiation (PPO)
a network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee. Premiums, deductibles, and copayments are usually higher than those paid for HMOs, but lower than regular fee-for-service plan.
primary care provider (pcp)
responsible for supervising and coordinating health care services for enrollees, and approves referrals to specialists and inpatient hospital admissions (except in emergencies)
quality assessment and performance improvement (QAP)
quality assurance activities are performed to improve the functioning of M + C organizations
quality assurance program
includes activities that assess the quality of care provided in a health care setting
Quality Improvement System for Managed Care (QISMC)
Medicare established (QISMC) to ensure the accountability of managed care plans in terms of objective, measurable standards (requirements). Plans are required to meet minimum performance levels and to share demonstrable and measurable improvements in specified broad clinical areas (e.g. preventive services, acute ambulatory care, chronic care, and hospital care) based on performance improvement projects that each plan identifies.
report card
containsdata regarding a managed care plan’s quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control
retrospectively
conducted after care has been administered.
risk contract
an arrangement among providers to provide capitated (fixed, prepaid basis) health care services to Medicare beneficiaries
risk pool
is created when a number of people are grouped for insurance purposes (e.g. employees of an organization); the cost of health care coverage is determined by employees’ health status, age, sex, and occupation
second surgical opinion (SSO)
a second physician is asked to evaluate the necessity of surgery, and recomment the most economic appropriate facility in which to perform the surgery (e.g. outpatient clinic or doctor’s office versus inpatient hospitalization)
self-referral
when an enrollee sees a non-HMO panel specialist without a referral from the primary care physician. The enrollee will have greater out-of-pocket expenses, as the enrollee must pay both a large deductible and 20 – 25% coinsurance charges, similar to those paid by persons with fee-for-service-plans.
staff model HMO
health care services are provided to subscribers by physicians employed by the HMO. Premiums and other revenue are paid to the HMO. Usually, all ambulatory services are provided within HMO corporate buildings
standards
requirements
survey
evaluation
triple option plan
is usually offered either by a single insurance plan or as a joint venture among two or more insurance carriers, provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans. It is also called a cafeteria plan or flexible benefit plan because of the different benefit plans and extra coverage options provided through the insurer or third-party administrator. Triple actions plans are intended to prevent the problem of covering members who are sicker than the general population (called adverse selection),
utilization management (utilization review)
is a method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care or retrospectively. Utilization management activities are performed by managed care plans and include, preadmission review, preauthorization, concurrent review, and discharge planning.
utilization review organization (URO)
Some managed care plans contract out with management services to a URO – an entity that establishes a utilization program and performs external utilization review services. Other plans contract with a third party administrator.
Health Plan Employer Data and Information set HEDIS)
sponsored by the National Committee for Quality Assurance, consists of performance measures used to evaluate managed care plans (e.g. rate of Pap smears performed among women of a certain age)
third party administrators (TPA)
an organization that provides health benefits clams administration and other outsourced services for self-insurance companies