Payor Plan Soup

Jackie Ruley

EDT6000

January 18, 2010

• Distinguish among the major types of plans, including HMO, PPO, EPO, and indemnity.

• Interpret the information provided on a patient’s insurance card.

• Select the correct payor plan.

Instructions• Click on the links in each session to advance.

Course Objectives and Instructions

START

Let’s get Started

CLICK HERE

CLICK HERE

Click PPO

What’s on a card?

Blue Cross/Blue ShieldDooble, Noodle Account NumberID Number 89676NOD129876

THE NOODLE COMPANYCOPAY: PCP SPEC ER

$10 $10 $40CUSTOMER SERVICE: (302) 437-0021

PPO

CLICK CROSS

Payor

Plan

What’s on a card?

CIGNA HMODUMPLINGS INC Group Number 123987ID Number: DUM89676

Dumpling, AppleCOPAY: PCP SPEC ER

$10 $25 $00CUSTOMER SERVICE: 1-800-437-0021

HMO

CLICK HMO

What’s on a card?

THE HERSHEY COMPANY

POSID W789 5324 GRP: 80734-768-72664

01 Mint, Cool 03 Mint, Curley02 Mint, Pop 04 Mint, ChocolateCOPAY: PCP SPEC ER

$20 $20 $00CUSTOMER SERVICE: 1 (800) 435-7266

AETNA

CLICK POS

Plan Type: PPO Plans

• Preferred Provider Organization

• Part of a “network”

• If a network provider is used, an adjustment or discount is taken

• If a out of network provider is used, out-of-pocket cost is higher

CLICK ORGANIZATION

• The entity that pays the claim

• Examples:– Aetna– Blue Cross– Cigna– Medicaid– Unision

What is a Payor?

1. CLICK Aetna – Review - CLICK “X” to close website

2. CLICK Cigna – Review - CLICK “X” to close website

CLICK HERE TO CONTINUE

What is a Plan?

The product line offered by the Payor

Plan Type: PPO Plans

Preferred Provider Organization

CLICK PPO

Plan Type: HMO

Health Maintenance Organization

CLICK HMO

The patient’s insurer, which consists of a payor and a plan.

Click on payor

Coverage Definition

Plan Type: POS

• Point Of Service• Treated as an HMO plan, but also has

out-of-network benefits• Patients have a Primary Care Physician (PCP)

or “gatekeeper” who manages their healthcare• Patients are typically subject to a deductible and

out-of-pocket costs if PCP does not authorize visit

• Authorizations are required for maximum benefits

CLICK HMO

Plan Type: HMO

• Health Maintenance Organization

• Also known as “managed care” plans

• Patients have a Primary Care Physician (PCP) or “gatekeeper” who manages their healthcare

• Co-Payment due at time of service

• Referrals and authorizations are required

CLICK GATEKEEPER

Plan Types: EPO

Exclusive Provider Organization

CLICK EPO

Plan Types: EPO

• Exclusive Provider Organization

• Some plans are treated as HMO and require authorization

• Other plans are treated as PPO and do not require authorization, but have no out-of-network benefits

• Very important that information is verified before patient is seen

CLICK HERE

Which Plan requires a Primary Care Provider

THP OA HMO

Every Payor needs a Plan?

CLICK PLAN

Let’s Review

• COB is for Coordination of Benefits, not a Plan Type, try again.

RUL POS COB EOB

CLICK HERE

Select the Plan Type

Blue Cross/Blue ShieldBean, Kidney Account NumberID Number 89676SNI129876

SNICKER VALLEY SCHOOL DISTRICTCOPAY: PCP SPEC ER

$15 $25 $40CUSTOMER SERVICE: (800) 437-0021

EPO

CLICK EPO

Let’s Review

• What is a Plan Type?

A. A Model

B. A Product Line

C. A TV Show

Let’s Review

• What is a Plan Type?

C. A TV Show – Sorry Try Again

CLICK HERE

Let’s Review

• What is a Plan Type?

B. A Product Line – Correct

Every payor has multiple product lines.

CLICK PLAN TYPE

Let’s Review

• What is a Plan Type?

A. A Model – WRONG

Try Again

CLICK TRY AGAIN

Let’s Review

• Select a Plan Type.

RUL POS COB EOB

Let’s Review

• EOB is an explanation of benefits. Select again.

RUL POS COB EOB

CLICK HERE

Which Plan requires a Primary Care Provider

THP – IS TOTAL HEALTH PLUS

SORRY

CLICK HERE

Which Plan requires a Primary Care Provider

OA - IS OPEN ACCESS

TRY AGAIN

CLICK HERE

Which Plan requires a Primary Care Provider

CONGRATULATIONS – YOU ARE CORRECT!

HMO requires that you select a Primary Care Provider to be your “gatekeeper”

CLICK HERE

Theend

CLICK THE END

Jackie Ruley

EDT 6000

January 18, 2010

Let’s Review

• Sorry Wrong Answer – TRY AGAIN

RUL POS COB EOB

CLICK HERE

Let’s Review

• Select a Plan Type.

RUL POS COB EOB

Yes, a POS is a Point of Service Plan.

It is treated as an HMO plan, but also has out-of-network benefits.

CLICK HERE

CLICK POS