Health Care Delivery Systems

Health Insurance

• Coverage that provides for the payments of benefits as a result of sickness or injury. Includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.

H M O’S• Health Maintenance Organization

• A managed care plan that integrates financing and delivery of a comprehensive set of health care services to an enrolled population.

• Enrollees are usually required to choose from among these providers and in return have limited copayments.

Group-Model HMO

• An HMO that pays a medical group a negotiated, per capita rate, which the group distributes among its physicians, often under a salaried arrangement.

INSURANCE

• Individual Insurance

• Policies purchased by individuals directly from an insurance company.

• These premiums are usually more costly than those associated with HMO’s.

Point-of-Service (POS) Plan

• A health plan with a network of providers whose services are available to enrollees at a lower cost than the services of non-network providers.

• POS enrollees must receive authorization from a primary care physician in order to use network services.

• POS plans typically do not pay for out-of-network referrals for primary care services

Preferred Provider Organizations (PPO)

A health plan with a network of providers whose services are available to enrollees at lower cost than the services of non-network providers. PPO enrollees may self-refer to any network provider at any time.

Health Savings Plans

• Employee has $taken out of net pay

• Some Employees donate or match $ saved up to a point.

• Dr. Visits, Meds, ER services etc, are automatically deducted from Balance of Savings Plan.

Medicare• The federal health benefit

program for the elderly and disabled that covers 35 million Americans or about 14% of the population for an annual cost of over $120 billion.

• Medicare pays for 25% of all hospital care and 23% of all physician services.

Medicaid

• Insurance program, funded jointly by the federal and state governments and managed by the states, that provides medical coverage for low-income families and individual

TennCare

• Some states manage their own version of Medicaid- like TennCare or CoverKids.

You tell me….

• What is the Omnibus Budget Reconciliation Act?

• What does it regulate?

• What population does this effect?

– Look it up in your book-

Who are these Organizations?

• WHO

• DHHS/DHS

• NIH

• CDC

• FDA

• OSHA

WHAT IS TENNCARE?

• January 1, 1994, Tennessee made history by withdrawing from the federal Medicaid program and implementing an innovative new health care reform plan called TennCare.

TennCare

• TennCare remains open to people who are Medicaid-eligible or who are uninsurable as determined by an insurance company (for medical reasons), as well as children under the age of 19 with access to health insurance whose individual family incomes are below 200% of the federal poverty level.

Definitions

• Benefit Package • Services covered by a health

insurance plan and the financial terms of such coverage, including cost sharing and limitations on amounts of services.

Definitions, cont’• Carrier :

• A private contractor, usually and insurance company, that administers claims processing and payment for Medicare Part B services

Definitions, cont’

• Copayment

A fixed dollar amount paid for a covered service by a health insurance enrollee

• Deductible The amount

paid by the patient for medical care prior to insurance covering the balance

Definitions, cont’

• Enrollee

• A person who is covered by health insurance.

• Fee-For-Service

• Type of payment used by some health insurers that pays providers for each service after it has been delivered

Definitions, cont’

• Health Care Provider • An individual or

institution that provides medical services (e.g., a physician, hospital, laboratory).

• Out-of Pocket Costs

• Total costs paid directly by consumers for insurance co-payment and deductibles, prescription or over-the-counter drugs, and other services.

Definitions, cont’

• Premium

• The amount paid or payable in advance, often in monthly installments, for an insurance policy.

• Primary Care Provider

• Health care professional capable of providing a wide variety of basic health services.

• Primary care providers include practitioners of family, general, or internal medicine; pediatricians and obstetricians; nurse practitioners; midwives; and physician's assistant in general or family practice

Benefit

• Insurance Plans offered by Employers is not required.

• It is offered as a “BENEFIT” for employees.