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