The CDHC (Consumer Directed Healthcare) movement is a movement in the health insurance industry that aims to empower members, reduce employer costs, and change the way consumers buy healthcare. This type of health plan offers financial incentives and other support tools to help members make decisions about their health care needs.
For decades, the Blue Cross conglomerate has grappled with organizational transformation and change, especially when it comes to health care reform. With the introduction of Medicare, competition from competing insurance companies, and rising health-care costs, the company’s involvement in the development of health maintenance organizations (HMOs) has met with some resistance. Miller uses a combination of sociological analysis, organizational theory, and oral histories to explain the evolution of Blues and HMOs.
Today, Blue Cross HMOs are managed by local affiliates. Although they do not participate in a national association, Blue Cross HMOs operate under the same principles. As a result, these health plans follow a system similar to government-wide Blue Cross/Blue Shield plans, such as the fee-for-service model. However, when a Blue Cross HMO joins a PPO network, costs are typically much lower.
In addition to employing representatives, HMOs market through their own informational materials and develop their own informational materials. The individual plans’ marketing may also limit enrollees’ choices and may favor healthier beneficiaries. To avoid such problems, HCFA has placed restrictions on these representatives’ activities and has mandated that marketing materials be reviewed.
The government may be paying HMOs more than is fair given that HMO prices are determined based on national averages, not by the characteristics of the FEHBP population. The government’s pricing system might be causing an aversion to HMOs among higher-risk populations. Lower-income, healthier people may benefit more from HMOs if prices are lower.
Choosing a Preferred Provider Organization (PPO) is an excellent way to receive quality medical care from a single provider. These plans can often be more affordable than traditional insurance plans. However, you must be aware of the costs and benefits of a Blue Cross PPO. These plans are not for everyone.
Anthem is one such insurer. Its PPO network includes the same doctors and hospitals as its EPO network. The company has recently added 3,800 more physicians to its network. In the past, PPOs have featured a PPO symbol on identification cards to protect consumers from being charged for out-of-network care. However, Anthem recently obtained association approval to reissue identification cards without the PPO symbol.
Another advantage of PPOs is that members don’t need to submit referrals for an OB/GYN. This means less paperwork and lower health care costs. However, it also means that members may have higher out-of-pocket expenses if they seek medical care outside their network.
Anthem’s PPO, which offers preferred access to participating physicians, has been subject to a lawsuit filed by customers. State managed care regulators are looking into the company’s practices. Some customers say that Anthem did not provide them with the information they needed to determine if they were eligible for PPO plans.
If you have a Blue Cross health insurance plan in North Carolina, you need to be certain that your claims are submitted using HCPCS or CPT codes. The guidelines for this are listed in the Hospital and Facility Guidelines. Blue Cross NC requires that physicians and hospitals use specific and detailed codes. The guidelines apply to both hospital-based physicians and those who act as billing agents.
Some of these plans also offer HSAs, which allow members to put money into tax-advantaged accounts. Funds withdrawn to cover qualified medical expenses are tax-free. HSAs are available at independent Blue Cross Blue Shield companies across the country. These insurance companies also provide claims processing services.
Direct deposit of provider payrolls
Blue Cross health insurance direct deposit of provider payroll is the process of providing payment to health care providers through electronic funds transfer. This process uses the automated clearinghouse network to transmit payments between health plans and providers. These payments are made electronically via bank account details provided by the providers. By providing their bank account information, health plans can deposit or withdraw funds to pay their providers.
Pre-existing condition coverage
Getting a plan with pre-existing condition coverage is essential if you have a pre-existing medical condition. Pre-existing conditions are medical conditions that you may already have, but have not been diagnosed with. Some pre-existing conditions are even excluded from individual market policies. However, pre-existing conditions can be covered if you are under age 19, pregnant, or have had “creditable” coverage in the past six months.
Typically, you must have had a pre-existing condition diagnosed by a health care provider within 12 months of the date of the plan’s effective date. Pre-existing conditions include illnesses that are chronic and require frequent, expensive care. While some health insurance plans may not cover these conditions, others may be better suited for people with chronic conditions that require regular medical care, surgeries, or treatments. A higher monthly premium may be worth it if you can get coverage with lower out-of-pocket costs.
Individual market insurers used to have lists of “declinable” medical conditions. If you had a past diagnosis of one or more of these conditions, you would be automatically denied coverage. These lists varied from company to company, but they had some overlap. As a result, many people were denied health coverage because of a pre-existing condition.
The Affordable Care Act created the Pre-Existing Condition Insurance Plan (PCIP), which makes health insurance more affordable for those with pre-existing conditions. This program is administered by the Department of Health and Human Services (HHS) and in many states. Some states administer their own program while others rely on a national insurance plan to administer benefits in the individual market.