C9 Healthcare Financing Flashcards

Question

CDHC plans have 3 basic elements?

Answer 1

▪High deductible insurance coverage ▪Health spending accounts (tax-sheltered) ▪Wellness/care management resources

Answer 2

▪Greater financial stake in medical spending, including choice between spending and saving available funds ▪More choice in health care providers ▪More information about provider costs and quality ▪More information about their own health problems, treatment alternatives and lifestyle choices affecting their health

Answer 3

Health Savings Account

Answer 4

Health Reimbursement Arrangement

Answer 5

▪ Permitted under I.R.C. for more than 25 years; precursor to CDHC ▪ Usually offered as a component of cafeteria plans (no accumulation)

Answer 6

▪HSAs permit pre-tax employee and employer contributions (usually through cafeteria plans) and taxfree withdrawals for qualified medical expenses ▪Assets are held and invested in separate account by outside custodian or trustee ▪Assets are never forfeited to employer and unspent funds accumulate year-to-year; no use-it-or-lose-it rule ▪No employer review and approval (adjudication) of account withdrawals; employees may withdraw for non-medical spending subject to paying taxes and (generally) 10% penalty ▪Eligibility for contributions to HSA conditioned on employee coverage under high deductible health plan (HDHP) and only limited coverage under low deductible plans ▪To qualify as HDHP, insurance coverage must satisfy minimum deductible and annual out-of-pocket maximum for single/family coverage (min/max limits apply for in-network expenses) ▪Primarily regulated by IRS; HSAs are not subject to ERISA if certain requirements are met; other federal health laws generally not applicable

Answer 7

▪HRAs permit tax-free employer contributions and taxfree withdrawals for qualified medical expenses ▪Employee contributions not permitted; employer contributions must be outside cafeteria plan ▪Usually unfunded; employer “contributions” are credited to bookkeeping reserves within employer general assets ▪Use-it-or-lose-it rule is not required (but is permitted). Employees may thus accumulate unspent account assets from year to year, but employer may set limit on permitted carryover ▪Employer or third party administrator reviews and approves (“adjudicates”) employee spending from HRA ▪Forfeitures of unspent amounts permitted at termination of employment ▪High deductible insurance coverage not required, but in practice most employers offer HRAs in conjunction with some form of high deductible plan

Answer 8

▪Health FSAs permit pre-tax employee contributions and tax-free reimbursements for qualified medical expenses ▪Usually funded by crediting employee salary reductions under cafeteria plans to bookkeeping reserves within employer general assets ▪Employer or third party administrator reviews and approves (“adjudicates”) employee spending from account ▪Use-it-or-lose-it rule applies: unspent funds are forfeited to employer at end of year; 2½ month grace period at year-end if plan so provides ▪Uniform coverage rule applies: entire annual salary reduction available for employee to withdraw at beginning of year

Answer 9

copayment-(payments on certain time-cost sharing), deductible-(payment prior to insurance paying for services rendered), or coinsurance-(part of FFS policy pays % of service cost)

Answer 10

provide benefits that include outpatient and inpatient services; surgery; laboratory testing; medical equipment purchases; therapies; and other services, such as mental health, rehabilitation, and prescription medications. ▪Most comprehensive policies have some exclusion attached to their policies.

Answer 11

basic or major medical policies, which reimburse hospital services, such as surgeries and expenses related to any hospitalization (also disease-specific policies and Medigap or medicare supp policies)

Answer 12

indemnity plans or fee-for-service plans, which have contracts between a beneficiary and a health plan but there is no contract between the health plan and providers. The beneficiary pays a premium to the health plan

Answer 13

HMOs, preferred provider organizations (PPOs), and point-of-service (POS) plans

Answer 14

the cost management of healthcare services utilization by controlling who the consumer sees and how much the service costs

Answer 15

Integrated managed care org into healthcare system

Answer 16

-Establish relationships with organizations and providers to provide a designated set of services to their members -Establish criteria for their members to utilize the MCO -Establish measures to estimate cost control -Provide incentives to encourage health service resources -Provide and encourage utilization of programs to improve the health status of their enrollees

Answer 17

The oldest type of managed care. Members must see their primary care provider first in order to see a specialist. 3 models: Staff, Group, Network

Answer 18

Hires providers to work at a physical location

Answer 19

Negotiates with a group of physicians exclusively to perform services. This was the first type of HMO model introduced by Kaiser Permanente

Answer 20

Similar to the group model, but providers may see other patients who are not members of the HMO

Answer 21

A group of physicians who are in private practice see MCO members at a prepaid rate per visit. The physicians may sign contracts with many HMOs

Answer 22

-Do not have a gatekeeper like the HMO, so a member does not need a referral to see a specialist -Do not have a copay but do have a deductible -Developed by providers and hospitals to ensure that nonmembers could still be served while providing a discount to MCOs for their members

Answer 23

Similar to PPOs but they restrict members to the list of preferred or exclusive providers members can use

Answer 24

Physician hospitals, surgical centers, and other medical providers that contract with a managed care plan to provide health services

Answer 25

provider is paid a fixed monthly amount per employee, which is often called a PMPM payment.

Answer 26

a type of fee for service but are discounted based on a fee schedule. The provider provides the service and then can bill the MCO based on the fee schedule.

Answer 27

In this instance, the provider is actually an employer of the MCO

Answer 28

Restriction on provider choice, gatekeeping, utilization review,

Answer 29

the primary care provider is the gatekeeper of all of the care for the patient member. Any secondary or tertiary care would be coordinated by the gatekeeper

Answer 30

evaluates the appropriateness of the types of services provided. There are three types of utilization reviews: prospective, concurrent, and retrospective

Answer 31

Implemented before the service is actually performed by having the procedure authorized by the MCO based on clinical guidelines

Answer 32

Decisions that are made during the actual course of service, such as length of inpatient stay or additional surgery

Answer 33

Evaluation of services once the services have been provided. This may occur to assess treatment patterns of certain diseases

Answer 34

Part of Medicare managed care. pay a premium per member that is based on a county-of-resident basis. Members could use both in-network and out-of-network providers. The risk plans covered all Medicare services and vision and prescription care

Answer 35

reimburse the MCOs on a preset monthly basis per enrollee based on a forecasted budget. The cost plans allowed members to pursue care outside the network

Answer 36

Allows PPOs as an option. Also allowed enrollees to participate in private fee-for-service (PFFS) plans as part of MA.

Answer 37

services that Medicaid is not obligated to pay for under an MCO contract (usually bc too expensive like mental health and substance abuse services)

Answer 38

established in 1990 to monitor health plans and improve healthcare quality -est HEDIS to measure service and quality of care

Answer 39

-As a result of the MCOs’ focus on cost, a physician’s ability to practice without close monitoring of their healthcare choices can be limited. -Surveys indicate that the more managed care networks the physician contracts with, the less satisfied they are with managed care

Answer 40

using Managed Long-Term Services and Supports (MLTSS), a CMS Medicaid program

Answer 41

-Physicians are unclear about MCO obligations. AMA has developed a National Managed Care Contract (NMCC). -Physicians are concerned with physician network rentals or silent PPOs, which are unauthorized third parties outside the contract between the MCO and the physician that gain access to the MCO discount rates -The main insurer who has the contract with the physician does not provide the information to the physician, and the third parties continue to benefit from the discounted rates

Answer 42

-Value-based reimbursement model: MCOs need to understand that both efficiency and quality are the highest priorities, not just efficiency. -Data-driven decision-making needs to be integrated into the culture. -Increasing drug costs: Focus more on generic drugs -Consumer advocacy: Marketing their plans is a necessity now

Answer 43

Healthcare sharing is a way for Christians to pay for their health care without using health insurance. When they have a medical need, Samaritan members receive support from other members and pay their healthcare providers directly from other members (membership fee)

Answer 44

eliminated lifetime and unreasonable annual caps or limits on healthcare reimbursement, provided assistance for the uninsured with preexisting conditions prohibited denial of insurance coverage for children with preexisting conditions, and extended coverage for dependents up to the age of 26 years

Answer 45

primarily financed from payroll taxes and is considered hospital insurance

Answer 46

a supplemental health plan to cover physician services. Part B covers two types of services: medically necessary services, or services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice; and preventive services, or health care to prevent illness

Answer 47

(1) Medicaid if the Medicare enrollee is eligible; (2) enrollment in MA, which can provide supplemental coverage; (3) employer-sponsored retiree insurance; (4) supplemental insurance policies from private insurance companies, which are called Medigap or medsup policies

Answer 48

plans cover all Medicare services and vision and prescription care

Answer 49

The Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA), which authorized Medicare Part D - purpose was to provide seniors with relief from high prescription costs

Answer 50

-funded by Medicare and Medicaid -provide the entire continuum of care and services to seniors with chronic care needs while maintaining their independence in their home for as long as possible

Answer 51

Employees are eligible for this program for medical care, death, disability, and rehabilitation services. Most employees receive 66% of their earnings, which is taxfree -employer funded contracts with insurance

Answer 52

Combines the healthcare resources of the uniformed services with networks of civilian healthcare professionals, institutions, pharmacies, and suppliers to provide access to high-quality healthcare services while maintaining the capability to support military operations.

Answer 53

Usually is defined as the professional charge for service/product performed or provided by a professional or facility. Customary is a range of fees that are typically charged in a geographic area. Reasonable is defined as a fee that is justified and relevant to the service or product.

Answer 54

Insurance, MCOs, and government

Answer 55

The employer has a contract with a benefit plan and pays a premium for each of its employees. (service-benefit plan) -MCO same amount paid no matter care type

Answer 56

Tax Equity and Fiscal Responsibility Act (TEFRA) and the Social Security Amendments of 1983 to manage Medicare cost controls

Answer 57

developed in the 1980s, are a system of codes that explain, the number of services and visits

Answer 58

This type of prospective payment system for skilled nursing facilities, used by Medicare, provides for a per diem based on the clinical severity of patients.

C9 Healthcare Financing Flashcards

(84 cards)