System and method for obtaining, maintaining and maximizing healthcare benefits

• US 8,126,727 B2
• Filed: 08/01/2007
• Issued: 02/28/2012
• Est. Priority Date: 08/01/2006
• Status: Active Grant

• Current Assignee: My Coverage Plan, Inc.
• Original Assignee: My Coverage Plan, Inc.
• Inventors: Peterson, Robert A.
• Primary Examiner(s): O'Connor, Gerald J.
• Assistant Examiner(s): PAULS, JOHN A
• Application Number:
  US11/832,288
• Publication Number:
  US 20080033756A1
• Time in Patent Office: 1,672 Days
• Field of Search: 705/2, 705/4, 705/3, 364/401
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/00 Administration; Management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 40/67 for remote operation
• CPC Class Codes: G16H 70/00 ICT specially adapted for the handling or processing of medical references

Abstract

A system and method for obtaining, maintaining, and maximizing health care coverage benefits for individuals and families is provided. Patient data is applied to health care coverage program criteria and a patient specific coverage report is generated. Notification alerts are generated and provide a users change event notifications. Proximity alerts are generated and provided within the coverage report, identifying potential loss and gain of coverage benefits and eligibility.

Claims

1. A method for obtaining and maintaining patient health care benefits comprising the following steps:

a. receiving patient data in a computer, the patient data relating to a patient and including demographic data, health data and financial data;

b. based upon the patient data, applying health care benefits program coverage criteria for one or more health care benefits programs to the patient data within the computer, wherein the health care benefits program coverage criteria include enrollment eligibility conditions for each health care benefit program;

c. within the computer, identifying;

(1) any health care benefits programs wherein the patient meets all of the health care benefits program coverage criteria for each of the health care benefits programs, thereby identifying the health care benefits programs for which the patient is currently eligible for enrollment;

(2) any health care benefits programs wherein the patient does not meet all of the health care benefits program coverage criteria for the health care benefits programs, but meets over at least 70% of the health care benefits program coverage criteria for the health care benefits programs, thereby identifying the health care benefits programs for which the patient is almost eligible for enrollment;

d. for any identified health care benefits programs for which the patient is currently eligible for enrollment;

(1) providing a benefits program enrollment application;

(2) submitting the benefits program enrollment application;

(3) receiving benefits program enrollment verification;

e. for any identified health care benefits programs for which the patient is almost eligible for enrollment, identifying the health care benefits program coverage criteria that must be met by the patient to attain eligibility for enrollment;

f. obtaining updated patient data;

g. after obtaining updated patient data, dynamically providing a report identifying;

(1) any health care benefits programs for which the patient is currently eligible for enrollment, and

(2) any health care benefits programs for which the patient is almost eligible for enrollment, and the health care benefits program coverage criteria that must be met by the patient to attain eligibility for enrollment;

h. providing a change event status notification, the notification identifying an actual or potential change event that alters benefits coverage based upon the patient data and health care benefits program coverage criteria.

2. The method according to claim 1 wherein identifying health care benefits programs includes:

a. calculating a probability of receiving enrollment verification;

b. reporting to the patient;

(1) a first health care benefits program as having the greatest probability of receiving enrollment verification, and

(2) a second health care benefits program as having a lower probability of receiving enrollment verification than the first health care benefits program,

wherein a third health care benefits program having a lower probability of receiving enrollment verification than both of the first and second health care benefits programs is also identified within the computer.

3. The method according to claim 1 wherein the change of event status notification provides a user with eligibility for enrollment and health care benefits program maintenance information, whereby the notification reduces the likelihood that the patient will become uninsured.

4. The method of claim 1 further comprising the following steps:

a. providing a competency test to a user, the competency test assessing the user'"'"'s knowledge of features of health care benefits programs; and

b. providing tutorials concerning features of health care benefits programs to the user in dependence on a score determined from the user'"'"'s competency test.

5. A method for maintaining and maximizing health care coverage comprising the steps of:

a. submitting patient data to a computer, the patient data relating to a patient and including demographic data, health data and financial data;

b. applying health care benefits program coverage criteria for several health care benefits programs to the patient data within the computer, wherein the health care benefits program coverage criteria include enrollment eligibility conditions for each health care benefit program;

c. within the computer, identifying one or more of the several health care benefits programs wherein the patient;

(1) meets all of the health care benefits program coverage criteria for the health care benefits program, thereby identifying a health care benefits program for which the patient is currently eligible for enrollment, and/or

(2) does not meet all of the health care benefits program coverage criteria for the health care benefits program but meets over at least 70% of the health care benefits program coverage criteria for the health care benefits program, thereby identifying a health care benefits program for which the patient is almost eligible for enrollment;

d. entering updated patient data into a memory storage device, wherein the updated patient data is dynamically applied to the health care benefits program coverage criteria;

e. upon or after entry of updated patient data, dynamically providing a report identifying;

(1) any health care benefits programs for which the patient is currently eligible for enrollment, and

(2) any health care benefits programs for which the patient is almost eligible for enrollment, and the health care benefits program coverage criteria needed by the patient to attain eligibility for enrollment;

f. providing a change event status notification, the notification identifying potential changes in patient eligibility for enrollment for one or more of the health care benefits programs.

6. The method according to claim 5 further comprising the following steps:

a. based upon health care benefits program existence, obtaining new health care benefits programs and new health care benefits program coverage criteria, wherein the patient data is applied to the new health care benefits programs; and

b. based upon eligibility for enrollment, generating a new report for a patient.

7. The method according to claim 5 further comprising the following step:

based upon all updated patient data, providing a health care benefits coverage proximity alert, wherein the proximity alert identifies potential health care benefits coverage programs for which the patient is almost eligible for enrollment.

8. The method of claim 5 further comprising the following step:

based upon all updated patient data, providing a health care benefits coverage proximity alert, wherein the proximity alert identifies potential loss of existing health care coverage.

9. The method of claim 5 further comprising the following step:

recording interactions between a first advocate and the patient, wherein the interaction recordation enhances advocacy for the patient when interacting with a second advocate.

10. The method of claim 5 further including the steps of:

a. calculating a probability of receiving enrollment verification;

b. identifying;

(1) a first health care benefits program as having the greatest probability of the patient'"'"'s enrollment;

(2) a second health care benefits program as having a lower probability of the patient'"'"'s enrollment than the first health care benefits program,

(3) a third health care benefits program as having a lower probability of the patient'"'"'s enrollment than the first and second health care benefits programs,

wherein at least the first and second health care benefits programs are reported in ranked order.

11. The method of claim 5 further comprising the following steps:

a. providing a competency test to a user, the competency test assessing the user'"'"'s knowledge of features of health care benefits programs; and

b. providing tutorials concerning features of health care benefits programs to the user in dependence on a score determined from the user'"'"'s competency test.

12. A system for identifying and maintaining consumer health care benefits including:

a. a database containing program data for health care benefits programs, the program data including health care benefits program enrollment eligibility criteria for participation in the health care benefits programs;

b. a memory storage device storing a consumer'"'"'s health care related data, including demographic data, health data, and financial data;

c. a computer processor in communication with the database and memory storage device, wherein the computer processor is configured to;

(1) apply the health care benefits program enrollment eligibility criteria to the consumer'"'"'s health care related data, and

(2) generate reports therefrom, the reports indicating;

(a) the consumer'"'"'s;

i. current eligibility for enrollment in one or more of the health care benefits programs based on the consumer'"'"'s health care related data, and

ii, future eligibility for enrollment in one or more of the health care benefits programs based on the consumer'"'"'s health care related data,

(b) one or more of the health care benefits programs for which the consumer;

i. is currently ineligible for enrollment, but

ii, meets over at least 70% of the health care benefits program enrollment eligibility criteria for the health care benefits programs, and

iii, would attain eligibility for enrollment with one or more changes in the consumer'"'"'s health care related data.

13. The system according to claim 12 wherein the reports generated by the computer processor are generated whenever a change occurs in the consumer'"'"'s health care related data.

14. The system according to claim 12 wherein the reports generated by the computer processor are periodically generated at a predefined frequency.

15. The system according to claim 12 wherein the reports indicating the one or more of the health care benefits programs for which the consumer is currently ineligible for enrollment include an indication of the changes needed in the consumer'"'"'s health care related data to attain eligibility for enrollment.

16. The system according to claim 12 wherein the reports indicating the one or more of the health care benefits programs for which the consumer is currently ineligible for enrollment include a report of first and second health care benefits programs for which the consumer is currently ineligible for enrollment, wherein:

a. the first health care benefits program requires fewer changes in the consumer'"'"'s health care related data to attain eligibility for enrollment than the second health care benefits program, and

b. the changes in the consumer'"'"'s health care related data needed to attain eligibility for enrollment are reported for each of the first and second health care benefits programs.

17. The system according to claim 12 wherein the reports indicating the consumer'"'"'s future eligibility for enrollment in one or more of the health care benefits programs include an indication of consumer submissions to the health care benefits programs that affect eligibility for enrollment.

18. The system of claim 12 wherein the reports further indicate, for the one or more health care benefits programs for which the consumer is currently ineligible, the changes in the consumer'"'"'s health care related data that must be made in order for the consumer to attain eligibility for enrollment.

19. The system of claim 12 wherein the one or more health care benefits programs for which the consumer is currently ineligible include:

a. a first health care benefits program having the greatest probability of the consumer'"'"'s enrollment;

b. a second health care benefits program having a lower probability of the consumer'"'"'s enrollment than the first health care benefits program,

c. a third health care benefits program having a lower probability of the consumer'"'"'s enrollment than the first and second health care benefits programs,

wherein at least the first and second health care benefits programs are provided in ranked order in the generated reports.

20. The system of claim 12 wherein the computer processor is further configured to:

a. provide a competency test to a user, the competency test assessing the user'"'"'s knowledge of features of health care benefits programs; and

b. provide tutorials concerning features of health care benefits programs to the user in dependence on a score determined from the user'"'"'s competency test.

21. A method for obtaining and maintaining consumer health care benefits including the following steps:

a. providing a consumer'"'"'s health care related data to a computer, wherein;

(1) the consumer'"'"'s health care related data include demographic data, health data, and financial data;

(2) the computer has program data for several health care benefits programs, the program data including health care benefits program enrollment eligibility criteria for participation in the several health care benefits programs;

b. providing an initial report to the consumer from the computer, the initial report;

(1) being based on a comparison between the consumer'"'"'s health care related data and the health care benefits program enrollment eligibility criteria; and

(2) indicating;

(a) one or more of the several health care benefits programs in which the consumer meets all of the health care benefits program enrollment eligibility criteria for the health care benefits program, thereby indicating health care benefits programs for which the consumer is currently eligible to enroll;

(b) one or more of the several health care benefits programs in which the consumer does not meet all of the health care benefits program enrollment eligibility criteria for the health care benefits programs but meets over at least 70% of the health care benefits program enrollment eligibility criteria for the health care benefits programs, thereby indicating health care benefits programs for which the consumer is almost eligible to enroll;

c. providing updated reports to the consumer from the computer, the updated reports;

(1) each being provided later in time than a prior initial or updated report, and

(2) indicating the consumer'"'"'s current eligibility for enrollment in one or more of the several health care benefits programs other than those indicated as currently eligible for consumer enrollment in the initial report.

22. The method of claim 21 further including the step of providing computer-assisted enrollment to the consumer for one or more of the several health care benefits programs.

23. The method of claim 21 further including the steps of:

a. periodically updating the consumer'"'"'s health care related data;

b. periodically updating the health care benefits program enrollment eligibility criteria;

c. providing updated reports to the consumer when;

(1) the consumer'"'"'s updated health care related data differ from the consumer'"'"'s previously-provided health care related data, or

(2) the updated health care benefits program enrollment eligibility criteria differ from previous health care benefits program enrollment eligibility criteria.

24. The method of claim 21 wherein the step of indicating health care benefits programs for which the consumer is almost eligible to enroll includes indicating the health care benefits program enrollment eligibility criteria that need to be met by the consumer to attain eligibility for enrollment.

25. The method of claim 21:

a. further including the step of calculating a probability of receiving enrollment verification;

b. wherein the reports provided to the consumer indicate;

(1) a first health care benefits program as having the greatest probability of the consumer'"'"'s enrollment, and

(2) a second health care benefits program as having a lower probability of the consumer'"'"'s enrollment than the first health care benefits program,

wherein the consumer is either;

i. currently eligible to enroll in, or

ii. almost eligible to enroll in, each of the first and second health care benefits programs.

26. The method of claim 21 further comprising the following steps:

a. providing a competency test to a user, the competency test assessing the user'"'"'s knowledge of features of health care benefits programs; and

b. providing tutorials concerning features of health care benefits programs to the user in dependence on a score determined from the user'"'"'s competency test.