Health plan management method and apparatus

• US 20020087444A1
• Filed: 11/21/2001
• Published: 07/04/2002
• Est. Priority Date: 11/21/2000
• Status: Active Grant

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: Trizetto Group Incorporated (Cognizant Technology Solutions Corp.)
• Inventors: DiPiero, Albert R., Sanders, David G.
• Granted Patent: US 7,624,026 B2
• Time in Patent Office: Days
• US Class Current: 705/35
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/04 Payment circuits
• CPC Class Codes: G06Q 20/28 Pre-payment schemes, e.g. "pay before"
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/06 Asset management; Financial planning or analysis
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 70/00 ICT specially adapted for the handling or processing of medical references

Abstract

Techniques and apparatus for managing contributions to an accruable health spending account in an employer-sponsored plan offering a member an employer-funded defined contribution, at least one insurance premium option and the ability to specify an allocation of the defined contribution for payment of option premiums and, in turn, a directed contribution amount designated to such accruable account are disclosed. The accruable account may be used to reimburse the member for qualified medical expenses, and the member may pay any premium shortfall using a tax-advantaged process such as a premium only payment plan. Also disclosed are techniques and apparatus directed to presenting member-specific out-of-pocket expenses for a selected procedure offered by at least one health-care provider.

Claims

1. A method of determining a directed contribution amount to an accruable health spending account for a member of an employer-sponsored health plan, comprising:

presenting an employer-funded defined contribution having a value for a given time period;

presenting at least one insurance premium option, the at least one insurance premium option defining an option cost for the given time period;

querying for a premium option selection based on the at least one insurance premium option, the premium option selection including a selection allocation less than or equal to the option cost;

receiving the premium option selection; and

calculating the directed contribution amount by subtracting either the selection allocation or the option cost from the defined contribution value.

2. The method of claim 1, wherein the given time period comprises at least one of a group consisting essentially of a day, week, month, and year.

3. The method of claim 2, wherein the defined contribution value, selection allocation, option cost, and the directed contribution amount are expressed in one or more units of currency.

4. The method of claim 1, further comprising presenting the directed contribution amount.

5. The method of claim 1, further comprising presenting a predicted contribution amount for the accruable health spending account, the predicted contribution amount based on either the defined contribution value or the option cost.

6. The method of claim 1, wherein said directed contribution amount calculating step comprises subtracting the selection allocation from the defined contribution value.

7. The method of claim 6, further comprising:

calculating a predicted contribution amount for the accruable health spending account by subtracting the option cost from the defined contribution value; and

presenting the predicted contribution amount.

8. The method of claim 6, further comprising:

calculating an out-of-pocket premium cost for the premium option selection by subtracting the selection allocation from the option cost.

9. The method of claim 8, further comprising presenting the out-of-pocket premium cost.

10. A method of paying an insurance premium of an insurance policy covering a member of an employer-sponsored health plan, the insurance policy defining a payor having a premium account, the method comprising:

A) calculating the out-of-pocket cost in accordance with the method of claim 8;

B) transferring a first amount from member funds to the premium account, the first amount substantially equivalent to the calculated out-of-pocket premium cost; and

C) transferring a second amount from employer funds to the premium account, the second amount substantially equivalent to the selection allocation.

11. The method of claim 10, wherein said transferring steps B and C comprise a single financial transaction.

12. The method of claim 10, wherein said transferring steps B and C comprise distinct financial transactions.

13. The method of claim 10, wherein

the member funds are pre-tax;

the accruable health spending account complies with section 105 of the Internal Revenue Code of 1986; and

said transferring step A complies with section 125 of the Internal Revenue Code of 1986.

14. A method of funding an accruable health spending account for a member of an employer-sponsored health plan, comprising:

determining the directed contribution amount in accordance with the method of claim 1;

and

transferring a first amount from an employer funded account to the accruable health spending account for the member, the first amount substantially equivalent to the directed contribution amount determined in said determining step.

15. The method of claim 14, further comprising:

withdrawing a sum from the accruable health spending account to reimburse the member for a medical expense.

16. The method of claim 14, further comprising:

withdrawing a first sum from a flexible spending account to reimburse the member for a medical expense; and

withdrawing a second sum from the accruable health spending account to reimburse the member for the medical expense when the first sum is less than the medical expense.

17. The method of claim 1, wherein the accruable health spending account complies with section 105 of the Internal Revenue Code of 1986.

18. A server-implemented method of determining a directed contribution amount to an accruable health spending account for a member of an employer-sponsored health plan, comprising:

issuing a first signal causing a client to present an employer-funded defined contribution having a value for a given time period;

issuing a second signal causing the client to present at least one insurance premium option, the at least one insurance premium option defining an option cost for the given time period;

issuing a third signal causing the client to query for a premium option selection based on the at least one insurance premium option, the premium option selection including a selection allocation less than or equal to the option cost;

receiving a fourth signal indicating the premium option selection; and

calculating the directed contribution amount by subtracting either the selection allocation or the option cost from the defined contribution value.

19. For use in determining a directed contribution amount to an accruable health spending account for a member of an employer-sponsored health plan, an information processor comprising a memory, said memory comprising computer readable program code for causing the information processor to:

issue a first signal causing presentation of an employer-funded defined contribution having a value for a given time period;

issue a second signal causing presentation of at least one insurance premium option, the at least one insurance premium option defining an option cost for the given time period;

issue a third signal causing issuance of a prompt for a premium option selection based on the at least one insurance premium option, the premium option selection including a selection allocation less than or equal to the option cost;

receive a fourth signal indicating the premium option selection; and

calculate the directed contribution amount by subtracting either the selection allocation or the option cost from the defined contribution value.

20. A computer program product for use in determining a directed contribution amount to an accruable health spending account for a member of an employer-sponsored health plan, comprising computer readable program code for causing an information processor to:

issue a first signal causing presentation of an employer-funded defined contribution having a value for a given time period;

issue a second signal causing presentation of at least one insurance premium option, the at least one insurance premium option defining an option cost for the given time period;

issue a third signal causing issuance of a prompt for a premium option selection based on the at least one insurance premium option, the premium option selection including a selection allocation less than or equal to the option cost;

receive a fourth signal indicating the premium option selection; and

calculate the directed contribution amount by subtracting either the selection allocation or the option cost from the defined contribution value.

21. A computer-implemented method for presenting out-of-pocket expenses for a procedure offered by at least one health-care provider tailored to a particular member of a health plan, comprising:

(A) obtaining a set of selected health-care providers and a procedure;

(B) for each one of the set of selected health-care providers, acquiring raw cost information for the procedure from a provider database;

(C) obtaining benefits structure information from a health plan database based on the member and the health plan, the benefits structure information including first data corresponding to the member and second data corresponding to the health plan;

(D) for at least one of the set of selected health-care providers, calculating a subscriber-specific cost based on the acquired raw cost information obtained in said obtaining step (B) and the first and second data obtained in said obtaining step (C); and

(E) presenting the subscriber-specific cost calculated in said calculating step (D) for the at least one of the set of selected health-care providers.

22. The method of claim 21, wherein the set of selected health-care providers comprises at least one member.

23. The method of claim 21, wherein

the set comprises a plurality of selected health-care providers;

wherein said calculating step (D) comprises calculating the subscriber-specific cost for each member of the plurality of selected health-care providers; and

wherein said presenting step (E) comprises presenting the subscriber-specific cost calculated in said calculating step (D) for each of the set of selected health-care providers.

24. The method of claim 21, wherein the first data comprises at least one of lifetime-maximum data, yearly-out-of-pocket maximum data, deductible data, copay data, and coinsurance data.

25. The method of claim 24, wherein the second data comprises allowable reimbursement rate data.

26. The method of claim 21, further comprising:

(F) for the at least one of the set of selected health-care providers, calculating a second subscriber-specific cost based on the subscriber-specific cost calculated in said calculating step (D) and at least one of a flexible-spending balance and an accruable health spending balance associated with the member.

27. The method of claim 21, further comprising:

(F) determining an alternative procedure based on the procedure and at least one of the benefits structure information, the subscriber-specific cost, and the set of selected health-care providers.

28. The method of claim 21, wherein said determining step further comprises determining the alternative procedure based on medical risks associated with the procedure.