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  1. 1. Heath Insurance
  2. 2. Evolution of Health Insurance• Historically, health insurance provided coverage for catastrophic illness and injury• It has evolved into coverage for preventative care and services• The traditional type of insurance is fee-for- service care
  3. 3. Managed Care Delivery Systems• This system integrates the delivery and payment of health care by contracting with select providers for a reduced cost• The goal is to provide health care with an emphasis on prevention
  4. 4. Types of Insurance Plans• Commercial health insurance plans• Indemnity-type insurance• Health maintenance organizations (HMOs)• Preferred Provider Organization (PPO)•• Consumer-driven health plans (CDHPs)• Government health plans
  5. 5. HMOs• Provide comprehensive health care with a focus on preventative care ▫ Annual physicals and PAP tests, well-child care• Members choose a Primary Care Provider (PCP) to oversee medical care ▫ PCP refers to a specialist, if needed
  6. 6. PPO, POS, IPA ▫ Preferred provider organization (PPO)  Members must select a PCP  Network of providers that provide services to members at a discounted rate (in-network)  Members pay more out of pocket for out-of-network providers ▫ Point-of-service (POS) plans  Members do not select a PCP and can self-refer to specialist ▫ Independent practice associations (IPAs)  Providers who practice in their own offices with their own staff
  7. 7. Consumer Driven Health Plans:DHPs• Health savings account (HSA) ▫ Must be paired with a qualified health plan• Health reimbursement account (HRA) ▫ Employers contribute to HRA (not employees)• Flexible spending account (FSA) ▫ Employees contribute to FSA ▫ Can pay for health insurance premiums, qualified medical expenses, dependent expenses
  8. 8. CDHP’s• Flexible spending account (FSA) ▫ Components  Health insurance premiums  Qualified medical expenses  Dependent care expenses ▫ Funded by the employee’s pretax dollars ▫ “Use it or lose it” plan
  9. 9. Government Health Plans• Medicare• Medicaid• Workers’ Compensation• TRICARE• CHAMPVA
  10. 10. Medicare• Created by the Social Security Act in 1965 – Administered by the Centers for Medicare and Medicaid Services (CMS)• Who is covered? – People over age 65 meeting eligibility requirements and have filed for Medicare – People who are disabled, receive Social Security benefits, or are in end-stage renal disease
  11. 11. Medicare• Part A ▫ Hospital coverage
  12. 12. Medicare• Part B – Other medical expenses, including office visits • X-ray and laboratory services • Initial Preventive Physical Exam• Part C – Enables beneficiaries to select a managed care plan as their primary coverage• Part D – Coverage for generic and brand-name drugs
  13. 13. Medicare and Claims Processing• Always keep up-to-date with Medicare requirements ▫ Must use CMS-1500 form ▫ Must submit Medicare claims electronically• Reimbursement to providers ▫ Medicare pays 80% of allowed amount after the deductible is satisfied ▫ 20% is paid by patient, or supplemental insurance
  14. 14. Medical Necessity• Medicare only reimburses services or supplies deemed reasonable and necessary for the diagnosis• Advance Beneficiary Notices (ABN) ▫ If a provider performs a service not covered by Medicare, an ABN is completed ▫ Must be signed by patient prior to procedure
  15. 15. Medicaid• Health insurance for limited or low-income individuals – Must use participating provider• Funded by both state and federal governments – Eligibility requirements and benefits vary by state – Medicaid cards are issued each month – Always verify current coverage prior to visit
  16. 16. Workers’ Compensation• State laws which cover employees who are injured while working or as a result of work• Benefits – Medical treatment in or out of a hospital – Temporary disability: may receive weekly cash benefits in addition to medical care – Permanent disability: weekly or monthly benefits, or a lump sum settlement – Payments to dependents for fatal injuries
  17. 17. TriCare• Beneficiaries ▫ Active service personnel and their dependents ▫ Retired active service personnel and their dependents ▫ Dependents of service personnel who died in active duty
  18. 18. CHAMPVA:Civilian Health and Medical Program of the Veterans’ Administration • Beneficiaries ▫ Spouses and children of permanently disabled veterans ▫ Spouses and children of veterans who died as a result of service
  19. 19. Patients with No Insurance• Classified as self-pay patients• These patients are expected to pay at the time of service
  20. 20. Primary and Secondary Insurance• Patients may have more than one insurance plan• Charges are filed first with the primary carrier, and then secondary ▫ Coordination of benefits• Dependent children and the Birthday rule
  21. 21. Primary and Secondary Insurance• Medicare and supplemental insurance ▫ Many Medicare patients have supplemental or Medigap insurance ▫ This covers the deductible and 20% coinsurance• Medicare as secondary insurance ▫ When a person qualifies for Medicare but is still employed
  22. 22. Verifying Insurance Coverage• Always ask patients for current insurance card• Make a copy of the card, or scan into the EMR• Verify coverage online or over the phone
  23. 23. Utilization Review• Preauthorization• Precertification• Predetermination• Concurrent review• Discharge planning
  24. 24. Fee Schedules• Providers enrolled in an insurance carrier’s network agrees to treat subscribers for an agreed upon (discounted) rate for services• Accepting assignment: when providers accept the allowed amount as the rate for services ▫ Disallowed amounts are written off as adjustments