Chapter 14 medical insurance Flashcards
a fixed percentage of covered charges paid by the insured person after the deductible has been met
coinsurance
the amount charged for a medical insurance policy
premium
a list of charges for services performed
fee schedule
federal law requiring disclosure of finance charges and late fees for payment plans
truth in lending act
an authorization to an insurance company to make payment directly to the physician
assignment of benefits
the max charge an insurance company or government program will cover for specific services
allowed charge
what does the coordination of benefits prevent?
duplication of payments
the fixed dollar amount that must be paid before insurer will pay additional expenses
deductible
the amount of money due from the insured to pay for a portion of the bill (paid before/after appt)
copayment
medicare is available to individuals who are
- 65 and older
- blind, widowed, or have long term disabilities
what is covered by medicare part A?
inpatient care
what is covered by medicare part B?
outpatient care
what is medicare part C?
allows private health insurance to provide medicare benefits
what is medicare part D?
prescription drug coverage
who can be covered by medicaid?
low income individuals
how is medicaid a different program from medicare?
medicaid is a health cost assistance program (not insurance)
who is the primary payer in medi/medi?
medicare
who is covered by TRICARE?
- current military
- retired military
- veterans
what are the 3 types of TRICARE?
- prime - HMO
- extra - managed care network
- standard - fee for service
who is covered by CHAMPVA?
families of veterans with disabilities
organizations that manage health care and sign up providers who agree to fixed fee services
managed care organizations (MCO)
prepaid program where insured are required to see participating providers (or specialists when referred)
health maintenance organization (HMO)
plan in which insured receive highest level of benefits when receiving services from specific providers and reduced benefits otherwise
preferred provider organization (PPO)
a system of payment where physicians and hospitals are paid a fixed amount for each patient enrolled over a period of time
capitation
permission needed from insurance carrier before giving a treatment
preauthorization/precertification
what is the difference between a group model HMO and a staff model HMO?
group - physicians see members of the HMO and nonmembers
staff - physicians work for the HMO and only see members
the reimbursement system for medicare part A is based on…
patients age
document that describes the reason for a denied insurance claim
explanation of benefits form
