Health Care Basics

US Health Care Basics

 Introduction to Health Care

 Health Benefits Basics
 Membership Types
 Plan Types
 Product Types
 Policy Types
 Various HealthCare Modules/Workstream
Health Benefits Basics

Essential Health Benefits:-

A set of categories of services health insurance plans must cover off. These include
• Doctors’ services
• Inpatient and Outpatient hospital care
• Prescription drug coverage
• Pregnancy and Childbirth
• Mental Health Services, and more

Cost Shares:-
Below are the foremost cost shares in health care.
• Deductible
• Copay
• Coinsurance

Deductible:-
The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you
pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered
services. Your insurance company pays the rest.
Family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family
members.
Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.
 Introduction to US Health Care

Health insurance protects you from owing a lot of money to doctors or hospitals if you get sick or hurt and need medical care.
Health insurance can also help you pay for regular check-ups, laboratory tests, vaccines, and prescription medication.
To get health insurance, you need to choose a health insurance plan, sign up, and then make regular payments (called
“premiums”) to a health insurance company. As long as, you remain eligible and keep paying your premiums, you will be “covered.” This
means that the health insurance company agrees to pay for part of your medical bills.
Health care in the United States is provided by many distinct organizations. Health Care facilities are largely owned and operated
by private sector businesses. 58% of community hospitals in the United States are non-profit, 21% are government-owned, and 21%
are for-profit
Healthcare coverage is provided through a combination of private health insurance and public health coverage
(e.g., Medicare, Medicaid).
About 64% of health spending was paid for by the government and funded via programs such as Medicare, Medicaid, the
Children’s Health Insurance Program (CHIP), and the Veterans Health Administration. People aged under 65 acquire insurance via their
or a family member's employer, by purchasing health insurance on their own, getting government and/or other assistance based on
income or another condition, or are uninsured. Health insurance for public sector employees is primarily provided by the government in
its role as employer.
Health Benefits Basics (Continued)
Copayment:-
A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
Let's say your health insurance plan’s allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20. If you've paid
your deductible: You pay $20, usually at the time of the visit. If you haven't met your deductible: You pay $100, the full allowable amount for the
visit.
Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.

Coinsurance:-
The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
Let's say your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20%. If you've paid your deductible: You
pay 20% of $100, or $20. The insurance company pays the rest. If you haven't met your deductible: You pay the full allowed amount, $100.

Example of coinsurance with high medical costs:

Let's say the following amounts apply to your plan and you need a lot of treatment for a serious condition. Allowable costs are $12,000.
Deductible: $3,000
Coinsurance: 20%
Out-of-pocket maximum: $6,850
You'd pay all of the first $3,000 (your deductible).
You'll pay 20% of the remaining $9,000, or $1,800 (your coinsurance). So your total out-of-pocket costs would be $4,800 — your $3,000
deductible plus your $1,800 coinsurance.
If your total out-of-pocket costs reach $6,850, you'd pay only that amount, including your deductible and coinsurance. The insurance company
would pay for all covered services for the rest of your plan year.
Membership Types & Health Plan Types

Membership Types:
Below are the various membership types in health care:
 Individual
 Groups
 Small Group
 Mid Size Group
 Large Group

Health Plan Types:

Below are the various health plan types:
 Medical
 Dental
 Vision
 Life
Product Types
Below are the various product types available in health care

Health Maintenance Organization (HMO)

A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO.
It generally won't cover out-of-network care except in an emergency.
An HMO may require you to live or work in its service area to be eligible for coverage.
HMOs often provide integrated care and focus on prevention and wellness.

Preferred Provider Organization (PPO):

A type of health plan where you pay less if you use providers in the plan’s network.
You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.

Exclusive Provider Organization (EPO):

A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an
emergency).

Point of Service (POS):

A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network.
POS plans require you to get a referral from your primary care doctor in order to see a specialist.
Policy Types

Commercial Policies:
Below are the Commercial (Private run) policies.
Individual Under 65 (IU65):
 Grandfathered is an individual health insurance policy purchased on or before March 23, 2010. These plans weren’t sold through the
Marketplace, but by insurance companies, agents, or brokers. They may not include some rights and protections provided under the
Affordable Care Act.
 Grandmothered is nothing but if your current health insurance policy is not grandfathered but was in effect prior to 2014, your plan is
considered as a “grandmothered” policy. These plans are not fully ACA-compliant and were purchased between March 23, 2010 – when the
ACA was signed into law and October 1, 2013
 ACA (On & Off Exchanges) The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or
“Obamacare”). The law has 3 primary goals: Make affordable health insurance available to more people. The law provides consumers with
subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level
Individual Over 65 (IO65):
 MedSupp and NGF

Government Policies:
Below are the Government run policies. They are operated and funded by different parts of the government and primarily serve different groups.
 Medicare is a federal program that provides health coverage if you are 65+ or under 65 and have a disability, no matter your income.
 Medicaid is a state and federal program that provides health coverage if you have a very low income.
 Various Health Care Modules/Workstream
Below are the Key Modules/workstreams, which define the core business functionalities to be validated-

Products & Benefits Enroll Bill Provider Claims

• Benefits configuration & • ID-Cards creation
Management • Correspondence and
• Product configuration & other fulfillment
Management functions
• Key downstream feeds
• Integration between
core and downstream
systems
• PCP auto assignment
• Billing Invoice • Provider contract • Claims intake, adjudication Individual
configuration • claim financial outputs (835,
generation, Grace
period management • Provider data setup refund requests)
• Bill Adjustments • Collaboration with • Encounters, interfaces extracts
PDM, Credentialing
and Contracting Large Group
systems

Small Group
Care Management Finance Customer Service Submit Encounter

• Integration with PHM • Integration with lockbox • Integration of Customer • Encounter Data Intake
platform for premium payments Service system and other • Encounter Data File Submission to
Mid Size Group
• Configuration of clinical edits • Integration with online portals CMS
• A&G functionality payment vendor • Issue & Service request and • Managing Rejected Encounters
• Payments associated with management • Reports
claims remittance and
corporate finance (GL)
Medicare 9
• Manage coordination with
finance transformation
program

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