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
