Notes

C930549
Join@618

HMO (Health Maintenance Organization)-requires PCP, PPO and No deductible, if in case the PCP is not available or decline service, the member should be refer to a PCP who is in network.
-is a pre-paid healthcare plan which provides and arranges basic health
-PREVIOUSLY PAID SERVICES.

Capitation- Negotiated amount between Health Net and the medical group where services is paid per member per month.
PCP- Assumes over all responsibility for the health of a member.
-also in charged of referral& providing prior authorization.
PPG- Participating Physician Group (medical Group)
-member's choice
-group of physicians contracted to Health Net
Access to care: PCP and PPG. (not all medical groups require a pcp)
Exception
Claims:
California: Capitation, Professional services are w/ Capitation

Arizona: FFS (Fee for service), professional service are paid on a contracted rate & there are required to bill Health Net.

Models:
1.) Group Model- is a group of doctors & providers own insurance.
- usually stay in one building (Ex. Kaisers)
2.) Network Group-Health Net

HMO members -> pcp/ppg -> pcp attends the care -> HN pays portion and members pays co payment and co insurance -> in case pcp refer, pcp provides referral to a pcp in network -> in case of out network make sure pcp is in contract with hn doesn't matter if ppg is not in contract.

CA Direct Network- When no Medical Group/PPG is available, Health Net assumes responsibility as the PPG/Medical group.
*eligibility-Member lives in a remote area and No PPG available in their area accepts New patients.

AZ HMO Open Access:
* Not required for PCP
*Member's can self-refer to any contracted specialist within the network.
*PPG required
*Open access to members MUST OBTAIN doctor's order to receive laboratory, Xray,PT & other services they may not self-refer
*claim in FFS
* There is plan deductible.

TIER 2 (PPO) Preferred provider organization
-self refer, deductible applies, provider lower co-payment & co-insurance to In-Network providers., If member went OON; greater OOPM responsibility to access type of care, doctors & hospitals agree to specific contract arrangements but are only paid FFS,
-Capitation doesn't apply.
-Access to care: PCP contracted to HN. No need to have PPG.

MAA (Maximum Allowable Amount)- Amount on which Health Net will only reimburse for covered services for OON. -reimbursement to the provider.

TIER 3 (OON) Out of Network
-Indemnity Plan-FFS, member may seek services to any licensed physician of there choice as long as the PCP is contracted.
Claims: Member will pay first before filing a reimbursement. Members must meet the deductible before they can get reimbursement.
-No co-payment but there is co-insurance.
-MAA-reimbursement here is to the member.

Types of Plans:
1) CA, AZ POS (Point of Service)
*Tier 1, Tier 2, Tier 3

2) CA Elect Open Access
*Elect 1-HMO-Best feature with the flexibility of PPO
*Elect 2-PPO-Required PCP, Can go to different PPG.

3) CA EPO- Exclusive Provider Organization
*Tier 1 & Tier 2= No deductible but requires co-payment and co-insurance.

First Health-Network of Doctors
PPO plan- PPO travel access program.
CA available with PPO Plan only.
Access first the website to check if the doctor is affiliated
Arizona-

Medicare- Federal Health Insurance Program
*Age 65 and older
*Have permanent kidney failure (ESRD)
*Who are "totally" disabled.
-enrollment is handled by social security within exchange
contact Medicare on 1-800-MEDICARE
www.medicare.gov

4 Parts of Medicare
A- Hospital Insurance (Facility)-covers hospital and skilled Nursing Facility
-covers only 60 days of confinement & more than 60-> daily co-payment.
B- Medical Insurance (Doctors, Provider, Medicare professional)- includes rendered at home, have to met deductible before paying 20% of the co-insurance and co-payment. have to pay deductible to take advantage of the benefits, rbvbs pays 80%, member pay 20%.
C- Medicare Advantage (Seniority Plus in HN)- private sectors can contract with Gov't but have to met the private policies. automatic HMO
D- Prescription Drug Program (Pharmacy Coverage)- not covered by HN.