MAA 102_Intro. Billing & Coding Lesson One Topic 2_Insurance Options & Categories

Health Benefits Plans Types Group health benefits Insured vs. self-funded Health care savings accounts Individual health benefits Government-sponsored (public) health benefits Medicare, Medicaid, TRICARE, CHAMPVA, and workers’ compensation

Less costly than traditional insurance Programs vary greatly Managed Care Programs Less costly than traditional insurance Programs vary greatly Contractual relationship with provider determines Prices charged Conditions of coverage

Elements of Managed Care Programs Precertification of hospital admissions required Approved referrals Network of providers contracted to provide services Assignment of benefits

Types of Managed Care Programs Health maintenance organizations (HMO) Preferred provider organization (PPO) Physician hospital organizations (PHO) Other programs

Types of Health Insurance Coverage Exclusive Provider Organization (EPO) Managed Care Plan Members are eligible for benefits only when they use services by a limited network of providers. Employers agree not to enter into an agreement with any other health plan Health Maintenance Organization (HMO) Provides wide range of comprehensive, preventative services at fixed periodic payment (capitation)

Types of Health Insurance Coverage Independent or Individual Practice Association (IPA) Managed care plan Program contracts with a number of physicians who agree to provide treatment to subscribers in their offices Paid capitation Subscribers have limited or no choice of providers Maternal and Child Health Program (MCHP) Federal program for children (<21) with special health needs. Assist parents with financial planning Assume part of treatment costs

Types of Health Insurance Coverage Preferred Provider Organization (PPO) Large employer with high number of employees contracts with a hospital or group of doctors to offer medical care at a reduced rate. TRICARE Government sponsored program Provides military medical services for spouses of active service personnel, dependent and retired service personnel Workers’ Compensation Insurance (WC) A contract that insures a person against injuries and illness on the job. Employer pays the premium for employees

A Health Plan With a PPO

Types of Health Insurance Coverage (cont’d.) Point-of-Service Plan (POS) Managed care plan Consists of a network of physicians and hospitals that provide an insurance company with discounts on its services. Patient can self refer

Types of Health Insurance Coverage Medicaid (MCD) Program sponsored by federal and state gov’t Provide health care benefits to individuals on public assistance, aged individuals with financial requirements, and the disabled. Coverage varies state to state.

Types of Health Insurance Coverage Medicare (M) National four part program For individuals over the age of 65, certain disabled, and ESRD Part A: hospital coverage Part B: supplemental coverage (example: physicain services, outpatient visits) Part C: Medicare Managed Care option Part D: Medicare Prescription Drug benefits

Workers’ Compensation Covers medical expenses of work-related illness and injuries Employer pays the premium for his employees.