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

2. 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

3. 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

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

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

6. 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)

7. 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

8. 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

9. A Health Plan With a PPO

10. 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

11. 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.

12. 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

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