Chapter 13-Other Healthcare Providers Flashcards
nonprofit membership based service organization established primarily for the purpose of providing hospital and medical expense payments directly to the provider
Blue Cross Blue Shield
a prepaid service organization that provides both the protection against healthcare expenses as well as the healthcare providers themselves; they specialize in prevention and managed care
Health Maintenance Organization (HMO)
general practitioner responsible for the oversight of a members care
Primary Care Physician
the primary physician acts as a ____________ to limit access to more expensive services of specialists and higher cost services
Gatekeeper
a minimal fee charged to encourage a doctor visit to avoid insureds delaying medical treatment
Co Pay
a ________consists of physicians that are employed by an HMO
Network
HMOs changed from an _________ to a _________ to allow physicians to maintain their individual practice as well as represent the HMO
Closed Panel System to an Open Panel System
a traditional insurance plan covering health care expenses as a prearranged discount
Preferred Provider Organization (PPO)
an HMO that allows the member to leave the HMO for treatment outside of the network
Point of Service
all insurance companies must provide__________within the policies offered to individuals and small groups
Essential Health Benefits
health insurance requirement for an individual
Individual mandate
coverage defined by the federal government that an individual must maintain for themselves and their dependents or they will receive an IRS tax penalty
Minimum Essential Coverage (MEC)
health plans certified by the ACA to meet requirements and offered through the Marketplace
Qualified Health Plan (QHP)
provides assistance with premium payments on plans purchased through the Marketplace
Premium Tax Credit (subsidy)
for those who but through the Marketplace, choose a Silver Plan and earn less than 250% of the Federal Poverty Level
Cost-Sharing Reduction
if an employer has over 50 Full Time Equivalent Employees health insurance must be provided
Employer Mandate
made up of full and part-time employees; part time employee hours are combined together, every combined 30 hours per week represents one full time
Full Time Equivalent Employees
program that gives the opportunity for small employers to allow their employees to choose their own plan in the Marketplace while the employer pay a portion of the premium
SHOP (Small Business Health Options Program)
several small employers of like industry, coming together for the purpose of buying insurance
Multiple Employer Trust (MET)
small business owners coming together with the purpose of self-insuring
Multiple Employer Welfare Association (MEWA)
an account established for the purpose of paying health care expenses with tax free money
Health Savings Account (HSA)
High Deductible Health Plan (HDHP)
Workers Compensation
workers comp is a _____________; fault does not need to be established
No Fault system
workers comp is ___________meaning the benefits are established by state law for recovery making suing not necessary
Exclusive Remedy
if an employer hires one or more employees they must provide workers compensation excluding certain industries (farm & domestic)
Compulsory Laws
disease that is a direct result of the occupation and is inherent to that occupation
Occupational disease
fund established through work comp designed to assist the employer in hiring a previously injured worker
Second injury fund
designed to cover accidents and sickness that occur outside of the workplace
Nonoccupational coverage
