EMPLOYEE BENEFITS MANAGEMENT 2

EMPLOYEE BENEFITS MANAGEMENT 2 - GROUP MEDICAL EXPENSE...

Info iconThis preview shows pages 1–5. Sign up to view the full content.

View Full Document Right Arrow Icon
GROUP MEDICAL EXPENSE BENEFITS (Ch. 9-14) I. Eligibility (Chapter 14, pp. 338-340) A. Very few rules 1. No nondiscrimination rules for insured group health plans 2. A few, limited nondiscrimination rules apply for self-funded plans B. Dependents usually eligible 1. Spouse 2. Unmarried children <19 (<23 if full time student) II. Federal Taxation (Chapter 14, pp. 367-368) A. Employer can deduct contributions (S162) B. Employer contributions not taxable to employees (S106) C. Employee contributions may be partially deductible 1. Qualifying medical expenses are deductible to the extent they exceed 7.5% AGI D. Benefits paid to employees tax-free (S105) III. Providers of Group Health Benefits (Chapter 9, pp. 203-209) A. Insurance Companies B. Blue Cross/Blue Shield plans C. HMOs D. PPOs E. Employers themselves (i.e., self-insurance) F. Government (Medicare, Medicaid) IV. Traditional Medical Expense Insurance (Indemnity) Plans (Chapter 10) 1
Background image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
A. Basic Coverages 1. Basic Hospital Expense Coverage 2. Basic Surgical Expense Coverage 3. Basic Physicians' Visits Expense Coverage B. Supplemental Basic Coverages 1. Extended Care Facilities* 2. Home Health Care* 3. Hospice Benefits* 4. Ambulatory Care (Surgicenters)* 5. Birthing Centers* 6. Diagnostic X-Ray and Lab Expense 7. Radiation Therapy 8. Prescription Drugs 9. Vision Care 10. Supplemental Accident Expense * Adding some supplementary Basic coverages can actually reduce total claim costs C. Major Medical Plans 1. Broad and Deep Coverage - See Covered Expenses, p. 253 a. Common Exclusions: expenses covered by WC, cosmetic surgery, physical exams, custodial care, dental care, routine eye/ear care, pre-existing conditions 2. Cost-sharing provisions a. Deductibles i. Individual and family ii. Carryover provision - Allows expenses that were (1) incurred during last 3 months of the year, AND (2) were applied to deductible, to also be applied to the following year's deductible b. Coinsurance provisions i. Apply after deductible ii. Usually written as 80%/20%, 70%/30%, etc. c. Stop-loss provisions ii. Out-of-pocket cap 3. Lifetime Maximum Benefits 2
Background image of page 2
a. Automatic annual restorations (common) b. Full restoration with evidence of insurability (common) V. Health Maintenance Organizations (HMOs) (Chapter 11) A. Characteristics 1. Finance AND deliver health care services 2. Comprehensive benefits 3. Limited patient choice i. Usually must use HMO provider ii. PCP as "gatekeeper" 4. Minimal cost-sharing 5. Focus on Cost Control i. Emphasis on preventive care ii. Emphasis on outpatient care iii. Limits on patient choice; PCP as gatekeeper iv. Physician compensation methods (1) Capitation (2) Salary (3) Bonuses B. Types of HMOs 1. Closed Panel plans a. Typically… - HMO contracts with a provider group - Physicians operate out of a number of common facilities - Physicians usually see only HMO patients - Provider group paid on capitation basis 2. Individual Practice Association a. Employer contracts with providers who have individual or group practices b. HMO subscribers can choose from restricted list of providers 3
Background image of page 3

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
c. Providers may serve both
Background image of page 4
Image of page 5
This is the end of the preview. Sign up to access the rest of the document.

This note was uploaded on 04/24/2008 for the course FN 4380 taught by Professor Sommer during the Spring '08 term at Saint Mary's University Texas.

Page1 / 14

EMPLOYEE BENEFITS MANAGEMENT 2 - GROUP MEDICAL EXPENSE...

This preview shows document pages 1 - 5. Sign up to view the full document.

View Full Document Right Arrow Icon
Ask a homework question - tutors are online