Types of Insurers

Question 1

Types of Insurers

List the types of health insurers and MCOs

Answer 1

• Indemnity Insurance
• Service Plans
• Managed Indemnity
• PPO
• EPO
• POS
• HMO
• CDHP
• Third-Party Administrator
• CO-OP

Question 2

Types of Insurers

Indemnity Insurance

Answer 2

Reimburse beneficiary for financial cost associated with health care

Question 3

Types of Insurers

Indemnity Insurance

Advantages and Disadvantages

Answer 3

• Adv = Simple
• Disadv = few controls to manage cost

Question 4

Types of Insurers

Service Plans

Answer 4

Similar to indemnity insurance, but with MC elements

• Plan contracts directly with providers
• No balance billing

Question 5

Types of Insurers

Managed Indemnity

Answer 5

MC overlays to combine with traditional indemnity insurance or service plans

Question 6

Types of Insurers

Managed Indemnity

MC Overlays

Answer 6

• UM
• Large care management
• Disease management
• Rental networks

Question 7

Types of Insurers

PPO

Answer 7

Entities that contract with network of “preferred” providers with cost-sharing incentives

Question 8

Types of Insurers

How are EPOs similar/dissimilar to PPOs and HMOs?

Answer 8

• Like PPO, but limits coverage only to in-network
• Doesn’t require PCP gatekeeper like HMO

Question 9

Types of Insurers

POS Plans

Answer 9

Combines HMO with indemnity type coverage for care received outside of HMO

Question 10

Types of Insurers

HMO Definition

Answer 10

Responsible for financial aspects of coverage and delivery system to provide covered services

Question 11

Types of Insurers

Things that Differentiate HMOs from Health Insurers

Answer 11

• Licensed by states under different laws than insurers
• Must provide adequate access to providers within its service area
• No balance billing clauses
• Direct access to PCPs
• Written policies for UM/QM and credentialing

Question 12

Types of Insurers

Open-Panel HMOs (Define, Examples)

Answer 12

• Contract with private physicians to provide care
• Examples: IPA, Direct Contract

Question 13

Types of Insurers

Closed-Panel HMOs (Define, Examples)

Answer 13

• Provide care through either medical group associated with HMO or physicians employed by HMO
• Examples: Group model, Staff model

Question 14

Types of Insurers

Open-Panel HMO Advantages/Disadvantages

Answer 14

• Advantages
  
  • Easily marketed
  • More convenient locations
  • Easier and less costly to set up and maintain
• Disadvantages
  
  • Little ability to manage care
  • Higher premiums

Question 15

Types of Insurers

Closed-Panel HMO Advantages/Disadvantages

Answer 15

• Advantages
  
  • Closely manage medical care
  • “One stop shopping” for members
• Disadvantages
  
  • Harder to market
  • Not convenient locations
  • More complex and costly to set up and maintain

Question 16

Types of Insurers

Types of HMOs

Answer 16

• IPA
• Direct Contract Model
• Group Model
• Staff Model
• True Network Model
• Mixed Model HMOs
• Open-Access HMOs

Question 17

Types of Insurers

Types of HMOs

Independent Practice Association (IPA)

Answer 17

HMO contracts with association of physicians (IPA) to provide service to members

Question 18

Types of Insurers

Types of HMOs

Direct Contract Model

Answer 18

HMO contracts directly with independent physicians or medical groups

• HMO does credentialing, network management, and UM

Question 19

Types of Insurers

Types of HMOs

Group Model

Answer 19

HMO contracts with multi-specialty medical group practice to provide all physician services to HMO members

Question 20

Types of Insurers

Types of HMOs

Staff Model

Answer 20

Physicians are employed by HMO

Question 21

Types of Insurers

Types of HMOs

True Network Model

Answer 21

HMO contracts with more than 1 medical group or physician organization

Question 22

Types of Insurers

Types of HMOs

Mixed Network Model

Answer 22

Mix of different model types

• Most common = closed-panel MCO adds open-panel components to their health plan

Question 23

Types of Insurers

Types of HMOs

Open-Access HMOs

Answer 23

Hybrid of POS and EPO

• Member selects PCP and gets best benefits using HMO, but can access specialty care directly with less coverage (POS)
• Only services provided by in-network providers are covered (EPO)

Question 24

Types of Insurers

Consumer-Directed Health Plan (CDHP)

Answer 24

Combine high-deductible health plan (HDHP) with pretax savings account

• Health costs are first paid from pretax account and then additional costs up to deductible are paid OOP

Question 25

**_Types of Insurers_** _Consumer-Directed Health Plan (CDHP)_ 2 Forms

Answer 25

* ER-Based = Health payment account (HRA) * Individual-Based = Health savings account (HSA)

Question 26

**_Types of Insurers_** Third Party Administrators

Answer 26

Administers benefits for self-funded ER group * Enrollment and claims processing * UM

Question 27

**_Types of Insurers_** Consumer-Operated and Oriented Plans (CO-OP)

Answer 27

Offers coverage to small groups and individuals through state exchanges

Question 28

**_Types of Insurers_** Types of Integrated Health Care delivery Systems

Answer 28

* IPA * Physician Practice Management Companies (PPMC) * Group Practice without Walls (GPWW) * Physician-Hospital Organizations (PHO) * Management Services Organizations (MSO) * Foundation Model * Provider-Sponsored Organizations (PSO) * Hospitals with Employed Physicians

Question 29

**_Types of Insurers_** Integrated Health Care Delivery Systems

Answer 29

Providers coming together to mange health care and contract with HMOs/PPOs/Insurers

Question 30

**_Types of Insurers_** Physician Practice Management Companies (PPMC)

Answer 30

* Publicly traded companies * Most failed because of the focus on needing to report positive earnings

Question 31

**_Types of Insurers_** Group Practice Without Walls (GPWW)

Answer 31

Physicians agree to aggregate their practices into single legal entity, but continue to practice in their independent locations

Question 32

**_Types of Insurers_** Physician-Hospital Organizations (PHO)

Answer 32

Entity that allows hospital and its physicians to negotiate with payers * PHO participants develop contract terms and use them to negotiate with payers

Question 33

**_Types of Insurers_** Management Services Organizations (MSO)

Answer 33

Evolution of PHO into an entity that provides more services to support physicians * Physician remains an independent private practitioner * MSO provides support services to member physicians

Question 34

**_Types of Insurers_** Foundation Model

Answer 34

Hospital creates a not-for-profit foundation, purchases physicians' practices, and puts those practices into the foundation

Question 35

**_Types of Insurers_** Provider-Sponsored Organizations (PSO)

Answer 35

Authorized to contract directly with Medicare on an at-risk basis for all medical services, bypassing existing Medicare HMOs * Resulted in deep financial losses

Question 36

**_Types of Insurers_** Hospitals with Employed Physicians

Answer 36

Hospitals employing both PCPs and specialists to increase hospital's negotiating leverage

Question 37

**_Types of Insurers_** ACO must be formed for the purpose of:

Answer 37

* Receiving and distributing shared savings * Repaying shared losses to CMS * Establishing, reporting, and ensuring provider compliance with healthcare quality criteria

Question 38

**_Types of Insurers_** Principles of PCMH

Answer 38

* Ongoing relationship with personal physician * Personal physicians provide/arrange all health care with team * Quality and safety are enhanced by evidence-based medicine with continuous quality improvement and patient engagement * Enhanced access to care through open scheduling, expanded hours, and better communication

Question 39

**_Types of Insurers_** PCMH vs. Gatekeeper PCP Model HMOs

Answer 39

* PCMH recognizes care team aligned around PCP (Like closed-panel HMOs) * PCMH focuses on quality and improvement aspects of PCPs role (Like HMOs)