1 / 21

Managed Care Update

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.

tyne
Download Presentation

Managed Care Update

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Managed Care Update Anthony N. Akosa, M.D.

  2. 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).

  3. Managed Care Organizations Types 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.

  4. 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.

  5. 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.

  6. 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 Survey

  7. Commercial Plan: Annual Premium Contribution

  8. Medicaid & Medicare cards

  9. 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.

  10. 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.

  11. 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.

  12. Medicare Drug Benefit

  13. 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.

  14. 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.

  15. 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.

  16. 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.

  17. 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).

  18. 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.

  19. IRS Requirements for HDHP in 2007

  20. HDHP Enrollment • 2005 – 1 million members • 2006 - 3.2 million members • 1/2007 – 4.5 million members Source: America’s Health Insurance Plans (AHIP)

  21. HSA vs HRA

More Related