managed care update
Post on 12-Jan-2016
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Managed Care Update
Anthony N. Akosa, M.D.
Types of Health Plans Medicare: managed by Centers for
Medicare & Medicaid Services (CMS). Products offered include traditional, Medicare Advantage (Part C) & Part D.
Medicaid: administered by the states. Commercial: offered by managed care
organizations (MCO) - private (MPlan, ADVANTAGE) and publicly traded (Anthem, Aetna).
Managed Care OrganizationsTypes of managed care plans HMO: Oldest form, least flexible, lowest
premiums. Must choose PCP to coordinate care.
PPO: Less restrictive. Services offered on a FFS basis. Financial incentive to stay within PPO network.
POS: A blend of HMO and PPO models. Selects PCP but can self refer, use OON providers.
Common Terminology Co-payment: a specified flat amount
paid for a specific service e.g. $10 for PCP office visits.
Coinsurance: % of the charge the plan and the patient share.
Out-of-Pocket Maximum: the maximum amount of coinsurance you will pay before the plan begins to cover 100% of the charges.
Common Terminology Deductible: amount required to be
paid by the insured before benefits become payable.
Spend-down: The medical expense relative to income that qualifies an individual for Medicaid. Similar to deductible as the amount is the member’s responsibility.
Commercial Plan: Market Share
PPO – 60% HMO – 20% POS - 13% HDHP – 4% Others – 3%
About 155 million Americans are covered by employer-sponsored health insurance
Source: Employer Health Benefits 2006 Annual SurveySource: Employer Health Benefits 2006 Annual Survey
Commercial Plan: Annual Premium Contribution
Single Coverage $ (employee/employer)
Family Coverage $ (employee/employer)
HMO $590 / $3459 of 4049
$3079 / $8198 of 11278
PPO $637 / $3749 of 4385
$2915 / $8850 of 11765
POS $634 / $3534 of 4168
$3226 / $7881 of 11107
HDHP $569 / $2836 of 3405
$2247 / $7238 of 9484
ALL PLANS $627 / $3615 of 4242
$2973 / $8508 of 11480
EmployeeContribution
15% of total 26% of total
Medicaid & Medicare cards
Medicare Of the 40 million Medicare beneficiaries,
89% were covered by traditional FFS plans in 2003.
The Medicare managed care product (Medicare Advantage) accounts for the remaining 11%.
Medicare Advantage offers additional benefits like prescription drugs, routine physicals, hearing aids, etc.
Medicare Premium: Most beneficiaries do not
pay Part A (hospital insurance). Part B (medical insurance) monthly premium for 2007 is $93.50.
Deductible: $131 annually for Part B. Beneficiaries pay 20% of Medicare approved amount for services after the deductible is met.
Medicare Drug Benefit The voluntary outpatient prescription
drug benefit (Part D) began January 1, 2006.
Standard Benefit: Estimated monthly premium of $37; deductible of $265; up to an initial coverage limit of $2,400.
Beneficiary pays 100% during coverage gap (“donut hole”).
Catastrophic coverage kicks in above stop-loss of $3,850.
Medicare Drug Benefit
PatientInsurance(ADVANTAGE PreferredPlus Part D Benefits)
$2.15 Generic$5.35 Brand or 5% (whichever is greater)
Pays claim balance
Stop loss limitOf $3,850
Pays 100% Pays $0
Initial coverage limit of $2,400
$10 Generic$29 Preferred Brand$58 Brand
Pays claim balance aftercopays
Medicare In addition to the Medicare part B
premium, Medicare Advantage beneficiaries have to also pay a monthly premium to the MCO.
Medicare Advantage premiums are lower than the Medigap (supplemental insurance) plans.
Medigap is sold by private insurers to fill the “gaps” in the original Medicare plan.
Medicaid Indiana Health Coverage Programs
(IHCP) Hoosier Healthwise Risk Based Managed
Care (RBMC) and Medicaid Select. Approximately 535,000 Hoosiers. Hoosier Healthwise was created in 1994
for low income Hoosiers with children, pregnant women and children.
Medicaid MDwise is the only locally owned and
operated, non-profit Hoosier Healthwise plan in the state.
The other MCOs are Anthem and Managed Health Services (MHS).
Medicaid Select (now called Care Select ) was created in Jan 2003 to take care of the aged (65 and over), blind and disabled.
Medicaid Reimbursement RBMC – MCOs paid capitated monthly
premiums. Medicaid Select – Fee-for-service and $4
PMPM administrative fee to providers. Administration fee to be increased to $15
PMPM in Nov 2007 when Care Select program is phased- in.
Additional $40 twice a year for communication.
High Deductible Health Plans (HDHP) Features higher annual deductible than
other traditional health plans. Maximum limit of the sum of annual
deductible and out-of-pocket medical expenses for covered expenses.
Usually includes an HSA (Health Savings Account) or an HRA (Health Reimbursement Account).
HSA (Health Savings Account) A tax-exempt trust or custodial account
created exclusively to pay for qualified medical expenses of the employee, spouse or dependents.
Employer usually contributes at least $500 for individuals or $1,000 for families.
Maximum contribution for 2007 as determined by IRS is $2,850 for individuals and $5,650 for families.
IRS Requirements for HDHP in 2007
Single Plan Family Plan
Minimum Deductible $1,100 $2,200
Maximum Out-of-Pocket $5,500 $11,000
HDHP Enrollment
2005 – 1 million members 2006 - 3.2 million members 1/2007 – 4.5 million members
Source: America’s Health Insurance Plans (AHIP)
HSA vs HRAHSA HRA
Do the funds belong to the employee
Yes No
Can the money be invested and earn interest
Yes No
Is it portable Yes No
Can funds be used for non medical expenses
Yes (IRS 10% penalty + tax)
No
Do the funds rollover year to year
Yes No(generally)
Can employees contribute Yes No
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