Ch. 2-Health insurance Flashcards
Adverse selection
Enrollment of an excessive proportion of persons with poor health status in a healthcare plan or healthcare organization
Appeal
Request for reconsideration of denial of coverage or rejection of claim
Benefit
Healthcare service for which the healthcare insurance company will pay
Benefit period
Length of time that a health insurance policy will pay benefits for the member, family, and dependents
Certificate of insurance
Formal contract between a healthcare insurance company and individuals or groups purchasing the healthcare insurance that details the provisions of the healthcare insurance policy
AKA certificate of coverage, evidence of coverage, or summary plan description
Claim
Request for payment, or itemized statement of healthcare services and their costs, provided by a hospital, physician’s office, or other healthcare provider.
Submitted to insurance plan by policyholder or provider
Coinsurance
Cost sharing provision which is a pre established percentage of eligible expenses to be paid by the beneficiary after the deductible has been met
Community rating
Method of determining healthcare premium rates by geographic area (community) rather than by age, health status, or company size.
Increases the size of the risk pool; costs are increased to younger, healthier individuals who are subsidizing older individuals
Coordination of benefits (COB)
Method of integrating benefit payments from multiple healthcare insurers to ensure that payments do not exceed 100% of the covered healthcare expenses
Co-payment
Cost sharing measure in which the beneficiary pays a fixed dollar amount per service, supply, or procedure that is owed to the healthcare facility by the patient
Cost sharing
Provision of a healthcare insurance policy that requires policyholders to pay for a portion of their healthcare services; cost-control mechanism
Covered condition
Health condition, illness, injury, disease, or symptom for which the healthcare insurance company will pay for treatment
Covered service
Specific service for which a healthcare insurance company will pay
Deductible
Annual amount of money that the policyholder must incur and pay before the health insurance plan will assume liability for the remaining charges or covered expenses
Dependent
An insured’s spouse, children and young adults(until they’re 26) and dependents with disabilities without an age limit
Children are defined as natural children, adopted children, stepchildren, and children who are dependent during adoption waiting period
Disease management
Program focused on preventing exacerbations of chronic diseases and on promoting healthier lifestyles for patients and clients with chronic diseases
Eligibility
Set of stipulations that qualify a person to apply for healthcare insurance
Employer-based health insurance
Coverage obtained by an individual or family as part of an employment benefit package
Enrollment
Initial process in which new individuals apply and are accepted as beneficiaries of healthcare insurance plans
Evidence-based clinical practice guidelines
Explicit statement that guides clinical decision making and has been systemically developed from scientific evidence and clinical expertise too answer clinical questions
Exclusion
Situation, instance, condition, injury, or treatment that the healthcare plan states will not be covered and for which the healthcare plan will pay no benefits
Family coverage
Healthcare insurance coverage for dependents of the policyholder, such as spouse and children
Formulary
A list of prescription drugs that a health insurance plan will cover or allow to be reimbursed
Gatekeeper
Healthcare provider or entity responsible for determining the healthcare services a patient or client may access
May be primary care provider, utilization review or case management agency, or a managed care organization
Guaranteed issue
Federal requirement that a healthcare insurer allow individuals to enroll in the health plan regardless of their health, sex, age, or other factors that might predict use of health services
Health maintenance organization (HMO)
Entity that combines the provision of healthcare insurance and the delivery of healthcare services
Characterized by; organized healthcare delivery system to a geographic area, set of basic and supplemental health maintenance and treatment services, voluntarily enrolled members, and predetermined fixed periodic prepayments for members coverage
Individual health insurance
Coverage that is purchased by an individual or family on their own (not through employer)
Limitation
Qualification or other specification that reduces or restricts the extent of the healthcare benefit.
Managed care
Payment method in which the third party payer has implemented some provisions to control the costs of healthcare while maintaining quality care
Systemic merger of clinical, financial, and administrative processes to manage access, cost, and quality of healthcare
Maximum out of pocket
Specific amount, in a certain timeframe, beyond which all covered healthcare services for that policyholder of dependent are paid at 100% by the healthcare insurance plan
Medically necessary
Healthcare services and supplies that are proper and needed for the diagnosis or treatment of medical conditions; are provided for the diagnosis, direct care, and treatment of medical conditions; meet the standards of good medical practice in the local area; are not mainly for the convenience of the beneficiary or the doctor
Moral hazard
The lack of incentive to guard against risk risk where one is protected from its consequences. Includes any change in behavior that occurs as a result of becoming insured
Open enrollment period
Period during which individuals may elect to enroll in, modify coverage, or transfer between healthcare insurance plans, usually without evidence of insurability or waiting periods
Other party liability (OPL)
Method of determining responsibility for health expenses when non health insurance sources are involved
Pharmacy benefit manager (PBM)
A specialty benefit management organization that provides comprehensive pharmacy services
They administer healthcare insurance companies prescription drug benefits for insurance companies or self-insured employers
Point-of-service (POS) plan
Managed care plan where members choose how to receive services at the time they need them
Members can choose at the point of service whether they want an HMO, a PPO, or a fee schedule plan
Policy
Binding contact issued by a healthcare insurance company to an individual or group in which the company promises to pay for healthcare to test illness or injury
Preferred provider organization (PPO)
Entity that contracts with employees and insurers, through a network of providers, to render healthcare services to a group of members
Members can choose to use the healthcare services of any physician, hospital, or other healthcare provider.
Network providers have lower out of pocket expenses than out of pocket expenses
Primary care provider (PCP)
Healthcare provider who provides, supervises, and coordinates the healthcare of a member
Includes general practitioners, internists, pediatricians, ob/gyns, nurse practitioners, physician’s assistants, etc.
Primary insurer
Entity responsible for the greatest proportion or majority of the healthcare expenses
Prior authorization
Process of obtaining approval from a healthcare insurance company before receiving healthcare services
AKA pre-certification, or pre-authorization
Prudent layperson standard
Standard for determining the need for emergency care based on what an ordinary person would believe or decide.
Qualifying life event (QLE)
Changes in an individuals life that make him or her eligible for a special enrollment period.
Ex: moving, marriage, divorce, income changes, etc.
Referral
A process in which a PCP makes a request to a managed care plan on behalf of the patient to send them to receive medical care from a specialist or provider outside the managed care plan
Risk
the likelihood of an individual to incur a healthcare expense or probability of incurring a loss
Secondary insurer
Entity responsible for the remainder of healthcare expenses after the primary insurer
Single coverage
healthcare coverage only for the policyholder/employee
Special enrollment period
an enrollment period limited to certain circumstances that occurs without regard to the health insurance company’s regularly scheduled open enrollment; driven by qualifying life events(marriage, death, divorce, birth, etc)
Summary of Benefits and Coverage (SBC)
A document that, in plain language, concisely details information about a health insurance company’s benefits and it’s coverage of health services
Supplemental insurance
policies that fill in the coverage of other policies; fills gaps of services not provided by main insurance
EX: accidental death, long term disability, short term health insurance for trip/vacation
Tier
level of coverage; act as limits
Utilization Management
a program that evaluates the healthcare facility’s overall efficiency in providing necessary care to patients in the most effective manner; primary cost control tool
Utilization review
a process that determines the medical necessity of a procedure and the appropriateness of the setting for the healthcare service in the continuum of care
Waiting period
period that must pass before coverage for an employee or dependent who is otherwise eligible to enroll under the terms of a group health plan can become effective
-does not apply to individual health plan; cannot exceed 90 days
Withhold amount
part of the provider’s prospective payment that the managed care plan deducts and holds to pay for excessive expenditures for expensive healthcare services such as referral to specialist
Major types of health insurance
Individual, employer-based, or government sponsored
Single or family coverage
Provisions of a health insurance policy
certificate of insurance describing conditions of the insurance policy(what is and isn’t covered) and the summary of benefits and coverage that simply details the company’s benefits and coverage
Characteristics of managed care
Quality- selection of providers, health of populations, care management tools, quality assessment and improvement
Cost-effectiveness- Service management tools(utilization management and review), prospective reimbursement, financial incentives
Common care management tools used in managed care
coordination of care, disease management, and application of evidence-based practice guidelines
Cost controls used in managed care
utilization management and review; gatekeeper rule of PCP; prior authorization; second and third opinions; case management; prescription management; payment rate established in advance of an episode of care; providers to meet fiscal targets; members to use providers associated with the plan
Types of managed care organizations
HMO (Health Maintenance Organization) -limited providers
PPO (Preferred Provider Organization) -more options for provider, benefits for using preferred
POS Plan (Point Of Service) -decide at time of service if it will be HMO, PPO, or fee schedule plan.
