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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.

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Managed Care Update

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  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

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