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Understanding Insurance Eligibility coverage & BENEFITSFor: Residential behavioral health setting,[object Object],Prepared by: Johana Désir,[object Object]
2009 ___ Insurance Data,[object Object],31% of VOB’s done in 2009 converted into admissions  ,[object Object],84%of the total admissions in 2009 were Insurance based,[object Object],± 2% margin of error ,[object Object]
In Network vs. Out of Network Coverage,[object Object],In Network – Per-Diem Rates contractually agreed upon by both parties. ,[object Object],Blue Cross Blue Shield-,[object Object],In-network at __ only with low daily rates requiring high OOP,[object Object],Out of network at ___ usually with a higher net revenue allowing for little OOP,[object Object], United Health Care-,[object Object],Out  of network at all  facility usually a higher net revenue allowing  for little OOP,[object Object], Cigna Health Care-,[object Object],Out of network at _________,[object Object],In-network at ________ (effective 10/7/2010),[object Object],Aetna-,[object Object],In-network  at ____ONLY (effective 7/1/2010) ,[object Object],Out of Network at ____,[object Object],Value Options- ,[object Object],In-network at ____,[object Object],Out of network at _____,[object Object],Compsych-,[object Object], In-network at ___,[object Object], Cannot go to ____ Will not pay Out of network providers,[object Object],Ad-Hoc Policies (GHI, MHN, Humana… etc),[object Object],Out  of network at all facility usually a higher net revenue allowing  for little OOP,[object Object]
In Network vs. Out of Network Coverage cont…,[object Object],Out of Network -  ___ has no contract with a specific insurance carrier for an agreed upon rates,[object Object],____ submit bills based on our “stated billed” charges or on the insurance “usual and customary” charges,[object Object],GHI, Humana, Principle life , MHN, or any Ad-Hoc plans,[object Object],Out of network at  facilities  usually have a higher OOP for the Patient, as a higher Net Rev for the facility,[object Object],Single Case Agreements- Special negotiated price between a provider and the insurance company(Payer),[object Object],Eligibility and benefits may not be applicable and/or no coverage available for a specific facility or Provider type,[object Object], Arrangements can be made, if allowed by the insurance, for the  policy to cover  a one time special approval for care,[object Object]
 Plan Types:,[object Object],Traditional PPO (Preferred Provider Organization) ,[object Object],PPOs allow the member to see any healthcare provider they want,[object Object],The premium for a PPO is generally higher than that of an HMO with a higher deductible and OOP cost for the member,[object Object],PPOs will pay between 70-80% of medical expenses ,[object Object],The use of OON benefits in PPO plan is often discouraged by insurance carriers,[object Object],Traditional HMO (Health Maintenance Organization),[object Object],The premium for an HMO is usually very low and has a low deductible and OOP cost for the member,[object Object],Requires members to see only doctors or hospitals within their network of providers,[object Object],Requires that the member chose a primary care physician, who will direct care and refer patients to approved providers,[object Object],Generally the HMO will not, cover medical expenses incurred by seeing a provider or facility not contracted with the HMO network,[object Object]
Insurance Coverage cont…,[object Object],EPO- (Exclusive Provider Option),[object Object],Type of managed care plan that combines features of HMOs and PPOs,[object Object],With an EPO, the member must select a primary care physician or physician gatekeeper who will be responsible for meeting your health care needs,[object Object],EPO plans  are much smaller than PPOs, they have a very limited number of providers who offer large discounts on their rates,[object Object],It is referred to as exclusive because the employer agrees not to contract with any other plan services ,[object Object],POS- (Point of Service) or Open Access,[object Object],POS plan is a hybrid of the HMO and PPO plans. Like an HMO plan, a primary-care physician and contracted doctors and facilities is given to the member, the PCP's role is to coordinate all aspects of the patient's health ,[object Object],But unlike an HMO, you may opt out of the network. If you opt out you'll be responsible for paying a portion of the provider's bills.,[object Object],Similar to a PPO plan, POS also  gives you the flexibility to seek doctor care in and out of network and still receive most of their insurance benefits,[object Object],With POS health insurance you have greater freedom, but at a higher cost,[object Object]
Eligibility and Benefits,[object Object],Eligibility,[object Object],Active Coverage,[object Object],Yearly renewal coverage (1/1/10 – 12/31/10),[object Object],Month to month coverage,[object Object],Self Funded,[object Object],Non-Active Coverage Types,[object Object],Cobra,[object Object],Exclusions to plan eligibility,[object Object],Certain doctors,[object Object],Levels of care; DTX, RES, REHAB, PHP and IOP,[object Object],Facility Type,[object Object],Required licensing and accreditation; STATE LICENSE, JACHO or CARF,[object Object],Pre-existing: based on certain diagnosis or prior credible coverage:,[object Object],An exclusion period imposed on the policy for a length of time. Any care must be given at the end of that period. The subscriber can choose to show proof of prior coverage to reverse the exclusion,[object Object],Exclusion can also be based on a certain diagnosis, usually chronic and often costly medical conditions such as: diabetes, heart problems, mental illness, cancer, COPD ,[object Object]
Eligibility and Benefits cont…,[object Object],Benefits,[object Object],General Benefits/Coverage - Medical, Dental, Vision, Durable Medical Equipment, Pharmacy,[object Object],Deductibles, Co-pays, OOP, Co-insurance, lifetime maximum, annual maximum applies to these benefits,[object Object],Behavioral Health Benefits-  overseen by the American Society of Addiction Medicine. (ASAM) Based on the Level of functioning (LOF), Level of Care (LOC) Chemical dependency (CD) resulting in the need for INPATIENT TREATMENT,[object Object],Deductibles, Co-pays, OOP, Co-insurance, lifetime maximum, calendar year maximum applies to these benefits,[object Object]
Government Funded PoliciesMedicaid and Medicare,[object Object],[object Object],Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services,[object Object],Each state may have its own name for the program. Examples include "Medi-Cal” in California, "MassHealth” in Massachusetts, "Oregon Health Plan” in Oregon,  and "TennCare”in Tennessee,[object Object],Medicaid is available only to certain low-income individuals and families who can't afford medical care pay for some or all of their medical bills,[object Object],Medicaid typically has a low reimbursement for services provided,[object Object],Most doctors, facilities, do notaccept medicaid,[object Object],Medicaid like most HMO Plans has a limit on which doctor or facility the member can obtain care,[object Object],Medicaid not accepted,[object Object]
Government Funded PoliciesMedicaid and Medicare cont….,[object Object],[object Object],Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. ,[object Object],The program also funds residency training programs for the vast majority of physicians in the United States,[object Object],Medicare program have four major parts, which operates as a single-payer health care system,[object Object],Part A Hospital Insurance ,[object Object],Part B Medical Insurance ,[object Object],Part C Supplemental (Medicare Advantage Plans),[object Object],Part D Comprehensive drug coverage,[object Object],Neither Part A ,Part B, C or D pays for all covered medical costs. The programs contain premiums, deductibles and coinsurance, which the covered individual must pay out-of-pocket,[object Object],Medicare can also be a supplemental plan for people who are aged 65 and over who are still employed and carry a primary or secondary commercial plan,[object Object]
Financials,[object Object],Patient Financial Responsibility,[object Object],IN-network and OON deductibles and Co-pays-a fixed dollar amount the patient is required to pay upfront before the policy begins to reimburse for services rendered, these dollar amounts usually renew every year,[object Object],Co-Insurance– Usually the 10% to 40% of  the cost that the policy will not cover after services has been rendered to the patient, the patient will be balance billed once payments has been received by  insurance,[object Object],Room and Board- Non-covered Servicefees NOT associated with the clinical care the patient receives while in treatment, such has lodging, food and laundry,[object Object],Pharmacy and/or miscellaneous- Fees associated with prescription  drugs that will be administered to the patient while in treatment,[object Object]
Behavioral Health Levels of Care,[object Object],Inpatient Residential Treatment ,[object Object],Average LOS – Most insurance plans covers 30 to 45 days for inpatient treatment base on medical necessity ,[object Object],Levels of care – Overseen by  The American Society of Addiction Medicine Assessment (ASAM),[object Object],Detoxification (DTX),[object Object], Average stay at DTX 5-7 days,[object Object],Based on acuteness of intoxication, withdrawal potential, biomedical conditions and complications. Emotional/behavioral conditions and complications, treatment acceptance/resistance , relapse and recovery environment.  Provided with a 24HR medical and skilled nursing supervision.,[object Object],Inpatient/Residential,[object Object],The highest intensity of medical and nursing care provided within a structured environment.  Persons require a more sustained treatment program in a controlled environment for stabilization and/or differential diagnosis ,[object Object],Average stay 8-10 days,[object Object]
Behavioral Health Levels of Care cont…,[object Object],Inpatient Residential Treatment,[object Object], PHP (Partial Hospitalization Program),[object Object], An intensive non-residential level of service where multidisciplinary medical and nursing services are required. ,[object Object],Average stay 8-10days,[object Object],Can also be performed on an Outpatient setting averaging 6 to 9Hrs,[object Object],IOP (Intensive Outpatient Program),[object Object], Multidisciplinary, structured services provided at a greater frequency and intensity than routine OP. These services  range from 90 minutes to 4 hours per day up to five days per week.  Common treatment modalities include individual, family , group, and medication therapy. ,[object Object], Average stay 15-25 days per program,[object Object],Outpatient/Therapy – Less intensive level of service provided by psychiatrists, psychologist, therapist and or counselors. Typically provided in an office setting from 60 to 90 minutes (for group therapies) per day,[object Object]
Pre-admission screening information,[object Object],Intake assessment,[object Object],Protected Health Information (PHI) HIPAA regulated,[object Object],Patient name, DOB, social security, home address,[object Object], Subscriber's name, DOB, social security, home address and employer,[object Object],Insurance Name and phone number,[object Object],Insurance ID number and group number ,[object Object],Clinical Data (Phone interview or Face to Face Assessment),[object Object],What (Drugs/Alcohol/Other substance),[object Object],Mental health/Psych related issue (Bi-polar, Anxiety, Depression),[object Object],When (last date of use and/or current pattern of use),[object Object],Biomedical conditions, Psych conditions,[object Object],How much, How often ,[object Object],Contributing family history/Psychosocial issues,[object Object],Why now(Precipitating events),[object Object],Placement  (Determination),[object Object]
References	,[object Object],http://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders ,[object Object],http://allpsych.com/disorders/dsm.html,[object Object],:http://psyweb.com/Mdisord/jsp/mental.jsp,[object Object],:http://bcbst.com/health-plans/group,[object Object],http://www.cms.gov/home/medicaid.asp,[object Object]

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Jd Revised Undestanding Insurance Eliigibilityprocess Iii

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Notas do Editor

  1. This presentation should help clarify some of your questions on insurance admissions and to respond to some basic question the patients may have prior to their admission.
  2. Why it is important to work the insurance intakes as much as the private pay intakes.
  3. Most commercial policy have either an in-network contract or out of network contract, with some policy having both in and out of network benefits.
  4. PPO affiliation: LAP in-network with BCBS/Magellan PPO, Value Options, Cigna/GM, Compsych. NO HMO. PPO affiliation: MH Out of network with all insurance (policy must have OON coverage)
  5. Eligibility: Policy must be effective prior to admission or treatment.Non active coverage: Policy termed or termination of employment or non payment for month to month policy.Cobra: Payment to extend coverage after policy term. Patient either pays directly to insurance company or bring the payment at admission along with the cobra paper work.Pre-exiting: Insurance companies impose an exclusion for care base on either a particular diagnosis or length of coverage.Benefits: Detail descriptions of what exactly the policy covers. What portion of care is the patient’s responsibility and what portion is the insurance responsibility.
  6. Mental health and substance care are base on different level of care base on medical necessity which make up the 30 days stay. Most patient will stay for 30 days in treatment at different level during that stay. The insurance companies have strict guidelines for qualification at those level of care. A full face to face assessment at the upon admission is required to determine at what level of care the patient will be placed.
  7. These are some basic information necessary for pre-admission and admission. The pre-admission step is a crucial part of the intake assessment in order to ensure a smooth admission in our facilities.