Types of Insurance Plans

There are several types of insurance plans, and most insurance companies offer plan levels. These plans have different types of coverage. Understanding the differences between the plans is essential in the coordination of care and reimbursement. These differences can include prior authorizations, billing codes, and time file limits.

Insurance plans that include home health coverage include the following: 

• Preferred provider organizations (PPO) 
• Consumer selects a primary care physician from a list of preferred or network providers 
• Plan may have copay, deductible, and/or coinsurance 
• Referrals require prior approval from the primary physician

• Point of service (POS) 

- Consumer selects a primary care physician 

- Plan may have copay, deductible, and/or coinsurance 

- Consumer is able to refer themselves to another physician

• Health maintenance organizations (HMO) 

- Consumer selects a primary care physician from a list of preferred or network providers 

- Most plans have copays; some may have an additional deductible 

- Referrals require prior approval from the primary care physician 

• Medicare prospective payment system (PPS) 

- Sixty-day episode of care 

- Covered 100%; may have copays in the future

 - Prior authorization of visits is not required

•  Medicaid 

- Sixty-day episode of care 

- Covered 100%

 - Some states require prior authorization of visits 

• Private insurance fee-for-service 

- Sixty-day episode of care 

- Some plans may have a deductible

 - Some plans may require prior approval from the primary physician 

• Accountable care organizations (ACO) 

- Consumer selects a primary care physician from a group of coordinated healthcare providers 

- Plan may have copay, deductible 

- Referrals are usually made to members of the ACO network; however, the consumer may go to any healthcare provider

ACOs are becoming more prominent among healthcare providers. An ACO is a network of physicians, hospitals, and post-acute providers that share financial and medical responsibility for providing coordinated care to patients with a goal of limiting unnecessary spending. See Chapter 10 for website information.