Chapter 2 - Health Insurance Models and Consumer Driven Health Plans Flashcards
Accountable Care Organizations (ACO)
A healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients.
Capitation
Fixed payment remitted at regular intervals to
a medical provider by a managed care organization for an enrolled patient
Carve Out
A service not covered in a health insurance
contract, usually reimbursed according to a different arrangement or rate formula than those services specified under the contract umbrella.
Consumer Driven Health Plans (CDHP)
Third tier insurance plans that give the members more control over their health budgets.
Copay
A specified dollar amount the policyholder must
pay to a healthcare provider for each visit or medical service received. This is typically found on the insurance card.
Credentialing
A process that is used to evaluate the qualifications
and practice history of a physician which includes a
review of a physician’s completed education, training, residency, and licenses.
Customized Sub-Capitation (CSC)
Managed care plan in which healthcare expenses are funded by insurance coverage; the individual selects one of each type of provider to create a customized insurance premium.
DEERS (Defense Enrollment Eligibility Reporting System)
A worldwide computerized database of all uniformed service members, their spouses and family members, and others who are eligible for TRICARE.
Deductible
An annual specified dollar amount the policyholder
must pay before the insurance carrier begins paying for services.
Employers’ Liability Insurance
Insurance that protects an employer from damages from a lawsuit resulting from an injury due to the employer’s negligence.
Exclusive Provider Organization (EPO)
An organization that has entered into contracts with medical care providers or groups of medical care providers to provide healthcare services
to members
Flexible Spending Account (FSA)
A tax-advantaged healthcare account an individual contributes money into that is used to pay for certain out-of-pocket healthcare costs.
Gatekeeper
A physician, typically a primary care physician,
like a family practitioner, internist, or pediatrician, who is responsible for determining a patient’s primary services and coordinating care so that the patient receives the appropriate needed services.
Group Health Plans
Health plans that are purchased by employers for its employees. A portion of the group health plan
premium may be paid by the employer
Group Practice Without Walls (GPWW)
A medical practice formed to share economic risk, expenses, and marketing efforts
Health Maintenance Organization (HMO)
An organization that provides comprehensive healthcare to voluntarily enrolled individuals and families in a geographic area by member physicians with limited referral to outside specialists, and that
is financed by fixed periodic payments determined in advance
Health Savings Account (HSA)
A savings account used in conjunction with a high-deductible health insurance policy that allows users to save money tax-free against medical
expenses.
Healthcare Reimbursement Arrangement (HRA)
An employer-funded plan that reimburses employees for incurred medical expenses that are not covered by the company’s standard insurance plan.
Individual Health Plans
Health plans that are purchased by individuals for themselves or their families, not as part of a
group plan.
Integrated Delivery Systems (IDS)
A network of affiliated facilities and providers working together to offer joint healthcare services to members.
Integrated Provider Organization (IPO)
A corporate umbrella for the management of diversified healthcare delivery system.
Managed Care Organization (MCO)
An organization that combines the functions of health insurance, delivery of care, and administration.
Management Service Organization (MSO)
A business providing nonclinical services to providers, like practice management service, to individual physician practices.
Medicaid
U.S. government program, financed by federal,
state, and local funds, of hospitalization and medical insurance for persons of all ages within certain income limits.
Medicare
U.S. government program of hospitalization insurance
and voluntary medical insurance for persons aged 65 and older and for certain disabled persons under 65.
National Provider Identifier (NPI)
A unique 10-digit identification number required by HIPAA.
Physician-Hospital Organization (PHO)
An organization that is owned by hospitals and physician groups working cooperatively
to develop improved methods of healthcare delivery,
oversee integration of physicians and hospitals into health delivery networks, assist in voluntary group formation, and collect, analyze, and disseminate information.
Primary Care Provider (PCP)
A healthcare practitioner, such as a family practitioner, internist, or pediatrician who is chosen
by an individual to provide continuous medical care, trained to treat a wide variety of health-related problems.
Privileging
Assesses the physician’s expertise in a specific
practice, like cardiology or surgery, based on documented competence in the specialty in which privileges are requested.
TRICARE
A coverage plan available for military personnel and
their families. It is extended to active and retired personnel.
Triple Option Plans
Allows an insurer to administer three
different healthcare plans so that members may select the benefit options they want: straight indemnity insurance, an HMO, or a PPO.
Workers’ Compensation Insurance
U.S. social insurance system for industrial and work injuries regulated at a state level.
