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Plan concept list


(Nadya Zvyagina) #1

Hello all!
Looks like the OMOP vocabularies contains the list of payer plan concepts only from the position of ‘metal’ category - Bronze, Silver, Gold & Platinum.
But there are no concepts for such plan types as: PPO, HMO, POS, EPO, CDHP, HDHP, Complex.
Is it possible to add concepts for these plan types as well?


(Christian Reich) #2

@nzvyagina:

Here is how it works:

  • Plan contains categories of concepts that define how much of the cost is covered by the insurance company, and what kind of care (dental, medical, drugs).
  • Payer defines how the insurance is set up, how providers are put into a network, and how they are paid.
  • Sponsor defines who buys the insurance.

In your list, PPO, HMO, POS and EPO are Payer concepts (342, 341, 331, 412), while CDHP (consumer-driven health plan) or HDHP (high-deductible health plan) means it is a Health Plan: 267 “Catastrophic Health Plan with 60% actuarial plan value”


(Nadya Zvyagina) #3

@Christian_Reich, thank you for the explanation!
It means that the majority of my payer plan records will be without plan (no plan_source_value and no plan_concept_id), they will contain payer information only.
Then I have a question about building a single payer_plan_period record… In order to build payer_plan_period record I used to merge records within a single plan value if there is no 32 days gap between plan periods. Does it mean that now I should merge them within one payer value (meaning the records without a plan) if there is no 32 days gap?


(Nadya Zvyagina) #4

One plan concept still seems missing.
There is no concept like ‘Commercial Managed Care other’. There is such a concept for Medicare 362 - ‘Medicare Managed Care other’ but nothing for Commercial. Is it possible to add this concept?


(Nadya Zvyagina) #5

And one more question appeared regarding plan mapping, what is the best map for

  1. Comprehensive plan
  2. Basic/Major Medical plan?

Is it correct to map
#1 to Platinum Health Plan with 90% actuarial plan value
and
#2 to Broad Benefit (Medical, Drug, Dental, Vision) plan
?


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