Ch 14: Basics of Health Insurance Flashcards
A recipient of health insurance benefits
Beneficiary
A contract between the health insurance plan and the provider 4 which the health insurance plan will pay an agreed-upon monthly fee per patient and the provider agrees 2 provide medical services on a regular basis
Capitation
A document sent by the insurance company 2 the provider and the patient explaining the allowed charge amount, the amount reimbursed 4 services and the patient’s financial responsibilities
Explanation of benefits
EOB
A reimbursement model in which the health plan pays the provider’s fee 4 every health insurance claim
Fee-4-service
The primary care provider, who can approve or deny when the patient seeks additional care via a referral 2 a specialist or further medical tests
Gatekeeper
Health insurance programs that r sponsored by the government and offer coverage 4 the elderly, military and indigent
- patients must meet the application requirements
Government-sponsored health insurance
An online service provided by various insurance companies 4 providers 2 look up patient insurance benefits, eligibility, claims status and explanation of benefits
Online provider insurance Web portal
Health insurance companies that operate 4 profit and use managed care plans 2 reduce the cost of healthcare
Privately sponsored health insurance
Low-income Medicare patients who qualify 4 Medicaid 4 their secondary insurance
Qualified Medicare beneficiaries
QMB
The intermediary and administrator who coordinates patients and providers and processes claims 4 self funded plans
3rd-party administrator
TPA
The person who is the signer on the health insurance policy
Subscriber
A process of managing healthcare costs by influencing patient care decision making by case-by-case assessments of the appropriateness of care
Utilization management
The amount of time that a patient waits 4 disability insurance 2 pay after the date of the injury
Waiting period
Health insurance plans that cover health services and procedures that r necessary 2 improve the patients current health condition
Medically necessary
Procedures that r not deemed medically necessary or needed 2 improve the patients current health
Ex. Facelifts
Elective procedures
Care which includes services provided to prevent certain illnesses
Preventive care
A privately sponsored health insurance plan purchased by an employer 4 a group of employees
Group policy
- offsets cost of medical care
- Defined as a contract 4 protection against financial losses resulting from illness and injury
- provides a payment of monetary benefits 4 covered sickness or injury, dependent on purchased policy
Purpose of health insurance
-to obtain health insurance, patients must apply either through their employer or privately
- 2 types of health insurance plans in the US:
- privately-sponsored health insurance plans
- government-sponsored health insurance plans
Contract w/ patients
- A type of health insurance plan
- employers usually sponsor A percentage of the monthly
Employer-sponsored group policies
A type of health insurance plan
-Individuals go out and purchase their own plan
Individual health insurance plans
A type of health insurance plan
- Passed in 2010
- increases the quality, availability, and affordability of private and public health insurance for more than 44 million unsure of Americans.
-Involves:
-Ambulatory patient services
-emergency services
-hospitalization
-maternity and newborn care
-mental health and substance abuse disorder services including
behavior health services
-prescription drugs
-rehabilitation and health habilitative services and devices
-Laboratory services
-preventative services and wellness services; chronic disease
management, pediatric services, including oral and vision care
The Affordable Care Act/Obamacare
A type of health insurance plan benefit
- Covers cost of all or part of the hospital room and board; and specific hospital services
- pays maximum amount per day and a maximum number of days
Hospitalization
A type of health insurance plan benefit
- Covers any surgical procedure, including but not limited to incision or excision; aspiration, standing; reduction of fractures
- his surgeons fees and assistant surgeon fees
Surgical
A type of health insurance plan benefit
- Covers outpatient and physician office procedures and services
- pays physicians fees; diagnostic, radiologic, laboratory, and pathology fees
Basic medical
A type of health insurance plan benefit
- Covers catastrophic or prolonged illness or injury
- takes over when basic medical hospitalization and surgical benefit and
Major medical
A type of health insurance plan benefit
- covers accident or illness resulting in and in the billet T for patient to work; can be paid whether work related or not
- pays cash benefits in Lou of salary while patient is an able to earn an income
Disability
A type of health insurance plan benefit
Covers preventative care; treatment and repair of teeth and gums
-typically pays 100% for preventative care and 50% for repair and treatment
Dental care
A type of health insurance plan benefit
- Covers our examinations and glasses or contacts
- page is set benefit amount, depending on care policy for examination and glasses
Vision care
A type of health insurance plan benefit
- Covers the deductible and coinsurance amount and paid by Medicare
- his deductible and coinsurance amount and paid by Medicare
Medicare supplement
A type of health insurance plan benefit
- Covers loss of life
- usually pays a lump sum upon the life insurance benefit
Life insurance
A type of health insurance plan benefit
- Covers long-term skilled nursing or rehabilitation care
- pays set amount is determined by policy benefits
Long-term care
A type of health insurance plan benefit
-coverage pays cost of all or part of:
-hospital room and board
-Policy is usually set maximum amount payable per day and
maximum days of care
Hospitalization
A type of health insurance plan benefit
- coverage pays all or part of a surgeons fees
- Some plans also paid for an assistant surgeon - coverage includes any incision or exigent, removal of foreign bodies Carme, aspiration, suturing, and reduction of fractures
- insurer frequently provides system subscriber with surgical fee schedule that is amounts insurer will pay for commonly performed procedures
Surgical
A type of health insurance plan benefit
- Pay all or part of his physicians fee for non-surgical services, including a hospital, home, and office visit.
- Patient usually pays deductible and a copayment or coinsurance payment each time
- may include a provision for diagnostic laboratory, radiology, and pathology all fees
Basic medical
A type of health insurance plan benefit
- Provides protection against large medical bills resulting from catastrophic or prolonged illness is
- covers most serious medical expenses up to a maximum amount, usually after a deductible and coinsurance have been met
Major medical
A type of health insurance plan benefit
- Insurance beneficiaries earned income against risk that a disability will make working uncomfortable, painful, or impossible
- encompasses paid sick leave and short term and long term disability benefits
- Many policies do not start payments until after a specified number of days or until a certain number of sick leave days have been used
- payment is made directly to individual, intended to replace lost income
Disability protection
A type of health insurance plan benefit
-May include reimbursement for all or a percentage of cost for refraction, lenses, and frames
Vision care
A type of health insurance plan benefit
-A supplemental health insurance policy to help defray medical costs not covered or only partially covered by Medicare
: Medicare supplements that cover Medicare recipients out-of-pocket expenses called Medigap policy’s
Medicare supplement
A type of health insurance plan benefit
- Covers losses to a third-party that caused by the insured
- Types include automobile business and homeowners policies
Liability insurance
A type of health insurance plan benefit
- provide payment of a specified amount on the insured’s death
- sometimes provides the monthly cash benefits if policyholder it becomes permanently and totally disabled
- Sometimes proceeds from life insurance are used to meet expenses of insured person’s last illness
Life insurance
A type of health insurance plan benefit
- Covers a broad range of maintenance and health services for chronically ill, disabled, or develop mentally delayed individuals
- services may be provided on an inpatient basis, on an outpatient basis, or at home
Long-term care insurance
A type of health insurance plan benefit
- Patients covered by an employer sponsored group health insurance plan typically share the cost for the monthly payment
- Individual health insurance market places have monthly fees
- indigent, elderly, federally employed employees or military patients who seek healthcare from the government have little or no monthly fees
Premiums
A type of health insurance plan benefit
Proof of health insurance coverage
Includes:
- health insurance company
- health plan name
- health plan type
- patients name
- subscriber ID
- Health plan contact phone numbers
Health insurance identification card
Healthcare facilities that are Contracted in the patient’s health insurance plan, including:
- medical offices
- urgent care centers
- hospitals
In network healthcare
Healthcare facilities that are Not covered by the patient’s insurance plan.
Out of network
Providers that are contracted with the insurance plan and have agreed to except the contract fee schedule
Healthcare providers can apply for this through a process called credentialing
Participating providers
PAR’s
A process of confirming the healthcare providers qualifications, including the healthcare providers license to practice medicine, affiliated organizations, and his or her education and professional background
Credentialing
The maximum amount that third-party payers will pay for a procedure or service.
Allowable charge
Two names for traditional healthcare insurance plans that pay for all or a share of the cost of covered services, regardless of which provider, hospital or other licensed healthcare provider is used
Referred to as a traditional plan because it preceded the advent of managed-care organizations (HMO‘s), Preferred provider organization ( PPO’s)and point of service (POS) plans.
Indemnity plans
-or-
Major medical
A health insurance plan where the health insurance company agrees to pay for certain surgical or medical services without additional cost to the person insured.
No set fee schedules
Premiums are higher but reimbursements are larger
Service benefit plans
America’s oldest and largest system of privately sponsored insurers
Created in 1900 from the lumber and mining camps of the Pacific Northwest and set the president for monthly prepaid healthcare
Providers agree to bill the patient only for the deductible and co-pay /co-insurance amounts that are based on their allowed rates, and the full charge for any uncovered services.
Blue Cross\Blue Shield
A type of healthcare organization
This organization contracts with various healthcare providers and medical facilities at a reduced payment schedule for their insurance members.
Patient care is coordinated through a diverse network providers and hospitals.
Different types include:
- HMO’s
- IPA
- staff model
- group model
- PPO
- EPO
Managed-care organizations
MCO’s
Passed in 1973 which provided for federal aid to health insurance pre-payment plans that Matt certain criteria, this legislation brought about a rapid growth in HMOs
Health Maintenance Organization Act
A type of MCO
They are state license health plans that are regulated by law that require them to include preventive care, such as routine physical examinations and other services, as part of their benefits package
Their goal is to reduce the cost of healthcare
Benefits include:
- lowest monthly premiums with lower patient financial responsibility
- Must select PCP
Health Maintenance Organization
A general practitioner who acts as the gatekeeper two more specialized care
Primary care Physician
PCP
A type of HMO
A group of providers other healthcare professionals under contract to provide services to members of different HMOs
A general or family practice provider or provider group that practices independently and they contract with several IPAs
Usually has a fixed fee per patient and can be structured as either captation or fee-for-service fee schedule
Independent Physician Association
IPA
A type of HMO
Hires salary to healthcare providers and contracts with providers to create and own the network
Medical care is authorized by the PCP
No captation or fee-for-service payment structure but has contract salary amounts
Staff Model
A type of HMO
They contract with a multi specialty medical group to deliver care to its members and usually practice together in one facility
Does not require a PCP and uses captation or fee-for-service repayment
Group Model
A type of MCO (not a HMO)
A managed care network that contracts with a group of providers; the providers agree on a predetermined list of charges for all services, including those for both normal and complex procedures.
The patients financial responsibilities represent on average 20% to 25% of the allowed charge, however, this depends on the patient’s health insurance benefits.
They furnish their subscribers with a list of participating providers in healthcare facilities from which they can access in network health care at reduced rates
Preferred Provider Organization
PPO
A type of MCO (not a HMO)
Combines features of an HMO and a PPO patients will not be covered for services outside it does need to network of providers (unless there is an emergency) but may not need to obtain a referral for specialized care
Members are not required to choose a PCP
Exclusive Provider Organization
EPO
Patients must obtain this in order to see some1 other than 1’s PCP
3 types:
- regular
- urgent
- STAT
Referrals
A type of referral
Usually takes 3 to 10 working days for review and approval. This type of referral is used when the provider believes that the patient must see a specialist to continue treatment.
Regular referral
A type of referral
Usually takes about 24 hours for approval. This type of referral is used when an urgent but not life-threatening situation occurs.
Urgent referral
A type of referral
Can be approved online when it is submitted to the utilization review department through the providers web portal.
It is used during emergency situations as indicated by the provider.
STAT referral
Requires pre-authorization in order to proceed with the procedure
Surgical procedures
Provides the following information:
- authorization code
- date on which the referral request was received by the utilization review department
- the date on which the referral was approved and it’s expiration date
- The exact time Authorization is valid
- authorized diagnosis and procedural codes
- name, address, and telephone number of the contracted specialist was the authorize services will be provided
- the comment section
- specified number of authorized visits to the specialist
- maybe issued for evaluation only, orEvaluation and treatment plan or evaluation and biopsy or evaluation and one injection and so on
Pre-authorization forms
They review individual cases to make certain that medical care services are medically necessary to ensure that providers are using the resources efficiently
Utilization review committee
A type of government sponsored plan
Established in 1966 and is the worlds largest insurance program
Provides healthcare coverage for individuals aged 65 and older, the disabled, and patients diagnosed with an stage renal disease (ESRD)
Medicare
A type of government sponsored plan
Part of Tittle XVIII of the Social Security Act
Is known as the Centers for Medicare and Medicaid services (CMS) and A division of the Department of Health and Human Services (DHHS) and laws are Enacted by Congress to regulate the program.
This plan is divided into four parts: Part A - Part D
Medigap is a optional policy That pays the deductible and the 20% co-pay meant for those who choose to pay for the additional coverage
Medicare
A type of government sponsored plan
Tittle XIX of Public Law 89 to 97, under the Social Security Amendments of 1965
Created to provide health care for the poor and needy but qualifications can very state to state. Their fee schedule is the lowest of all insurance companies and is not always in the medical offices financial interest to accept these patients
Qualified patients include:
- poor and medically needy
- recipients of AFDC (needto Families with Dependent Children)
- receiving SSI
- certain types of state or federal aid
- QMB’s (qualified cat Medicare Beneficiaries)
- receiving long term care
Medicaid
A state-funded program for children whose family income is above the Medicaid qualifying income limits.
Premiums are typically 5% of the family monthly income and covers routine check ups, immunizations, doctor visits, prescriptions, dental care, vision care, inpatient and outpatient hospital care, laboratory tests, x-rays, and emergency services.
Children’s Health Insurance Program
CHIP
A part of the Medicare plan
Covers:
- inpatient hospital care
- skilled nursing facilities
- home health care
- hospice services
Monthly premium: $0
Deductible: $1288 deductible for each benefit period
Part A
A part of the Medicare plan
Covers:
- outpatient hospital care
- durable medical equipment
- providers services
- other medical services
Monthly premium: $104.90
Deductible: $166 +20% coinsurance for all medical services
Part B
A part of the Medicare plan
Covers:Expanded inpatient hospital and outpatient hospital care benefits
Monthly premium: varies by plan
The duct a bowl: varies by plan
Part C
A part of the Medicare plan
Covers: prescription drugs
Monthly premium: varies by income
Deductible: varies by plan
Part D
A type of government sponsored plan that serves all military personnel
Congress passed the Dependents medical Care Act of 1956 and the Military Medical Benefits Amendments of 1966. This allowed the Secretary of Defense to contract with civilian healthcare providers. This became known as the Civilian Health and Medical Program of the Uniform Services (CHAMPUS)
TRICARE
A type of government sponsored plan in all 50 states
And insurance plan for individuals who are injured on the job either by accident or an acquired illness.
Benefits include:
- medical care and rehabilitation benefits
- weekly income replacement benefits for temporarily disability
- permanent disability settlements
- survivor benefits when applicable
Paid for by employers; Patients receive no bills.
Workers Compensation
