1. Johnsen, Susan G. MSN, RN, COS-C

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Q: My agency requires us to inform the patient of their financial responsibility for home healthcare services. I'm confused about the difference between HMOs and PPOs. Also, are copays and coinsurance the same thing?


Home healthcare has changed significantly over the past 50 years. Although it was once an almost purely Medicare fee-for-service payment system, we now see many more patients with various types of insurance, including Medicare Advantage Plans. As a result, home care staff must be aware of patient insurance coverage both when it comes to visits as well as when it comes to supply usage. Not all insurance payers are created equal. The discussion below is a general one, as there are as many variations as there are health plans and how they arrange cost sharing varies not only from plan to plan but also regionally.


Preferred provider organizations (PPOs) and health maintenance organizations (HMOs) are both considered managed care plans, but they are very different. A PPO allows patients to choose any physician they wish. However, physicians within network will cost the patient less money. An HMO restricts the patient to see only providers within a network or group of physicians. These networks are made up of groups of healthcare providers who include primary care and specialty care physicians along with clinical labs, medical equipment suppliers, and very often home healthcare agencies.


HMOs typically do not have an annual deductible and require only copays for medical care. This can include home healthcare agency visits. They generally require a referral from the primary care provider for all services other than obstetrics/gynecology.


Generally, PPOs do not require referrals but each one is unique. Some have deductibles, copays or coinsurance, and it will probably be higher for out-of-network services. This again includes home healthcare agencies.


So, about those copays and coinsurances? What is the difference?


Copays and coinsurances are ways the insurance companies share the cost of healthcare with patients. The main difference is how the cost is shared between the patient and the insurance. Deductibles factor in here too. Many PPOs have a deductible that must be paid first, before the insurance company pays for anything beyond that. That deductible may be high or low. High deductibles usually result in lower monthly premiums.


Copays are fixed dollar amounts. For example, the patient might pay $20 dollars to see a physician, each time they see that physician, or for a home healthcare agency visit. Coinsurance is a percentage. With a coinsurance, you pay a percentage of the cost of the healthcare until you reach the plan's maximum out-of-pocket for the year. Typical coinsurances are 20% to 30% of the cost with the insurance company paying the rest.


PPOs generally have negotiated rates for many services, so the patient pays the coinsurance only on the negotiated rate if the provider is in network. Some plans may have both copays and coinsurances but not for the same service. A patient may pay a copay for a doctor's visit but have a coinsurance for a hospital stay.


Why is this important? As home healthcare providers, we are expected to provide the patient with notice of what they are expected to pay before care is provided. This is a part of the financial consent process. Supplies fall in here as well, as the coinsurance for supplies may be different from the actual visit or might be included in the visit rate. It will depend on the insurance and whether your agency has a contract with the insurance plan.


Copays and coinsurance may be different for home healthcare nursing and home healthcare therapy and some services may not be covered at all depending on the insurance policy. This is particularly true for home healthcare aide services (which are often considered custodial) and for social work visits.


What about Medicare Advantage Programs-how are HMOs and PPOs similar and different?


Medicare Advantage Plans, also known as "Medicare Part C," are Medicare-approved health insurance plans that allow a patient to utilize both their Medicare Part A and Part B benefits. It applies to all services except hospice. (If a patient with a Medicare Advantage Plan requires hospice care, their traditional Medicare will cover it.) Medicare Advantage HMOs and Medicare Advantage PPOs share the characteristics of being a single source of healthcare coverage. Most also offer Part D (prescription drug coverage). Some plans also offer vision and hearing coverage-patient's need to read the fine print. Both also have networks of healthcare providers from hospitals to physicians to home healthcare agencies and medical equipment suppliers.


Medicare Advantage Plan HMOs and PPOs have a defined service that varies in size from counties to entire states. Within this area, they contract with their network of providers, which will include pharmacies if they also offer Part D benefits. To make the most of their coverage, a patient with a Medicare Advantage Plan will want to stay in network.


Medicare Advantage Plans are supposed to provide at least the same benefits as traditional Medicare (except hospice). Like their traditional counterparts, they have deductibles, copays, coinsurances, and out-of-pocket expenses. Unlike traditional Medicare, they have limits on what a patient must pay out of pocket in each year. The amount will vary from plan to plan.


Medicare HMOs and PPOs differ in important ways. In an HMO, the patient chooses a primary care provider (PCP) who provides the routine medical care. He or she is responsible for coordinating care by referring the patient to in-network providers for hospitals, labs, medical supplies, or home healthcare.


PPOs give more flexibility in the choice of healthcare providers and typically do not require the patient to select a PCP. Patients can see any healthcare provider they choose, but their out-of-pocket expense will be higher if the provider is not in network. The patient is often responsible for coordinating care and assuring the provider has authorization when seeking care out-of-network. No matter which Medicare Advantage Plan, Medicare is paying the insurance provider to meet the patient's healthcare needs.


Data From Landmark National Institutes of Health Blood Pressure Study Supports Important Part of New AHA/ACC Hypertension Guidelines

Findings from a landmark study funded by the National Institutes of Health support a key component of the new 2017 Hypertension Clinical Practice Guidelines announced by the American Heart Association (AHA) and the American College of Cardiology (ACC) at the annual AHA meeting in Anaheim, California November 2017.


In 2013, the National Heart, Lung, and Blood Institute (NHLBI), part of the NIH, adapted to changing times and refined its focus to generating high quality scientific evidence in support of the development of clinical practice guidelines worthy of the public trust. The new high blood pressure guidelines illustrate the utility and impact of NHLBI scientific studies. Today the AHA and the ACC issued the first comprehensive new high blood pressure guidelines in more than a decade that indicate high blood pressure should be treated earlier with lifestyle changes and in some patients with medication - at 130/80 mm Hg rather than 140/90. An important component of these guidelines was informed by the results of the Systolic Blood Pressure Intervention Trial (SPRINT), a clinical study sponsored in part by the NHLBI and designed to determine the best way to treat blood pressure in adults with hypertension, 50 years or older, who are at high risk for heart disease.


SPRINT, which began in the fall of 2009, included more than 9,300 participants, recruited from about 100 medical centers and clinical practices throughout the United States. It remains the largest study of its kind to date to examine how maintaining systolic blood pressure at a lower than previously recommended level would impact cardiovascular and kidney diseases.