Chapter 2- Overview of the Health Insurance Payment System Flashcards
Disability Insurance
Insurance providing income to a policyholder who is disabled and cannot work.
Health Insurance
A contract between the subscriber and the insurance company to pay for medical care and preventive services
Affordable Care Act (ACA)
Landmark health reform legislation intended to lower health care costs and provide health care coverage to millions of uninsured Americans. it was signed into law by president Obama in March 2010.
Health Insurance Identification Card
Card given to subscriber as proof of insurance
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Mandates government regulations that govern patient privacy, security, and electronic record transactions.
Self-Pay
a patient with no health insurance who must pay out of pocket for medical care
Primary
the insurance plan that is billed first for medical services
Secondary
the insurance plan that is billed after the primary has paid or denied payment
Supplemental
another name for secondary insurance. A supplemental plan usually picks up the patients deductible and/or co-insurance
Medigap
supplemental insurance for patients with medicare as their primary. These plans may pick up the medicare deductible and co-insurance
Contract
an agreement between two or more parties
Identification Number
the number on the identification card that identified the patients employer group health plan
Plan Type
a specific name assigned by the insurance company designating a specific plan for that type of insurance. for example, Oxford has a “liberty” plan.
Policyholder
the person who has )carries) the health insurance
Subscriber
another term for policyholder
insured
another term for policyholder or subscriber
beneficiary
term used for a patient who has Medicare coverage
Co-Payment
a flat fee the patient pays each time for medical services. this is associated with managed care plan
Co-insurance
a percentage the patient is responsible to pay of the cost of medical services. this is associated with indemnity, traditional, and commercial health insurance plans
Deductible
the amount the patient is responsible to pay before any reimbursement is issued by the insurance company. this is usually associated with indemnity, traditional, or commercial plans
indemnity plan
a type of insurance plan in which reimbursement is made at 80 percent of the allowed amount, and the patient pays the remaining 20 percent
Allowed Amount
the dollar amount an insurance company deems fair for a specific service or procedure
Fee schedule
a list of allowed amounts for all service and procedures payable by the insure comapny
Traditional
another term for indemnity or commercial health insurance plans
Commercial
another term for indemnity or traditional health insurance plans
Government Plan
a health insurance plan funded by the government
Centers for Medicare and Medicaid services (CMS)
a government agency that oversees the Medicare and Medicaid programs
Medicare
a government health insurance plan primarily covering persons aged 65 and older
Medicaid
a government plan for financially indigent people
Medicare Part B
cover services such as provider exams, surgeries, lab and radiology tests, durable medical equipment supplies (such as canes, oxygen, and wheelchairs) considered medically necessary to treat a patients condition
Outpatient
services performed at a facility where the patient stays less then 24 hours and is not admitted to the facility; also the term for the patient receiving such services.
Orignal Medicare
healthcare coverage managed by the federal government
Carrier
a company that has contracted with CMS to pay Part B claims
Fiscal agent
a company that contracts with CMS to pay Medicaid claims
Eligibility Category
a category listing requirements for a person to be covered by a specific plan
Manged care plan
a health insurance plan that includes financing, management, and delivery of health care services
Primary Care Provider (PCP)
a provider (or other health care provider) who is responsible for a patients main health care
Specialist
a provider who specializes in a particular area of medicine
Prescription drugs
medications prescribed by a provider (or other licensed prescriber)
Emergency room visits
an encounter in the emergency room
Health Maintenance organization ( HMO)
a prepaid medical service plan that provides services to plan members
In network
medical care sought from participating providers within a managed care plan
Out of Network
medical care sought from nonparticipating providers; those providers who have not contracted with specific managed care plans
Preferred Provider organization (PPO)
this type of plan offers discounts to insurance company clients in exchange for more members
out of pocket
the patients share of the cost of health care services. this can include co-payments, co-insurance or an deducible
Point- of- service (POS)
plan a health insurance plan in which the patient pays a co-payment when staying in network
Medicare Advantage
a private company that contracts with Medicare to offer and mange a plan for Part A and Part B Medicare heath insurance benefits.
Medicare Part C
plans run by private companies that combine coverage for both hospitals and provider visits for an out of pocket fee
Referral
permission from the primary care provider to seek services from a specialist for an evaluation, testing, and/or treatment. managed care plans require this
Tricare
Health insurance provided for retired military personals, active military personal , and their dependants
Tricare Prime
the only tricare plan offering coverage for active-duty service members. retired members may also select this plan
Military Treatment Facility (MTF)
a place where tricare members receive medical treatment
Preferred Provider Network (PPN)
a group of civilian medical providers that has contracted with Tricare
Tricare Standard
a Tricare plan available only to retired military service members and their families. this plan is available both in the United States and oversees.
Tricare Extra
a Tricare plan available only to retired military service members and their families. this plan is not available oversees
Coverage
existence and scope of the existing health insurance
Individual
the one and only person covered under a health insurance plan
Employee
a person employed who is covered under an employers group health plan
Husband/Wife (H/W) Coverage
health insurance covering both the husband and wife
Employee/Significant other (E/S) Coverage
health insurance covering the employee and the employees significant other
Parent/Child coverage
health insurance coverage for a parent and child
Family coverage
health insurance coverage for the individual employee, the employees spouse and the employees children
Dependents
persons covered under the policyholders plan
