Chapter 2- Overview of the Health Insurance Payment System

Question 1

Disability Insurance

Answer 1

Insurance providing income to a policyholder who is disabled and cannot work.

Question 2

Health Insurance

Answer 2

A contract between the subscriber and the insurance company to pay for medical care and preventive services

Question 3

Affordable Care Act (ACA)

Answer 3

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.

Question 4

Health Insurance Identification Card

Answer 4

Card given to subscriber as proof of insurance

Question 5

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Answer 5

Mandates government regulations that govern patient privacy, security, and electronic record transactions.

Question 6

Self-Pay

Answer 6

a patient with no health insurance who must pay out of pocket for medical care

Question 7

Primary

Answer 7

the insurance plan that is billed first for medical services

Question 8

Secondary

Answer 8

the insurance plan that is billed after the primary has paid or denied payment

Question 9

Supplemental

Answer 9

another name for secondary insurance. A supplemental plan usually picks up the patients deductible and/or co-insurance

Question 10

Medigap

Answer 10

supplemental insurance for patients with medicare as their primary. These plans may pick up the medicare deductible and co-insurance

Question 11

Contract

Answer 11

an agreement between two or more parties

Question 12

Identification Number

Answer 12

the number on the identification card that identified the patients employer group health plan

Question 13

Plan Type

Answer 13

a specific name assigned by the insurance company designating a specific plan for that type of insurance. for example, Oxford has a “liberty” plan.

Question 14

Policyholder

Answer 14

the person who has )carries) the health insurance

Question 15

Subscriber

Answer 15

another term for policyholder

Question 16

insured

Answer 16

another term for policyholder or subscriber

Question 17

beneficiary

Answer 17

term used for a patient who has Medicare coverage

Question 18

Co-Payment

Answer 18

a flat fee the patient pays each time for medical services. this is associated with managed care plan

Question 19

Co-insurance

Answer 19

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

Question 20

Deductible

Answer 20

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

Question 21

indemnity plan

Answer 21

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

Question 22

Allowed Amount

Answer 22

the dollar amount an insurance company deems fair for a specific service or procedure

Question 23

Fee schedule

Answer 23

a list of allowed amounts for all service and procedures payable by the insure comapny

Question 24

Traditional

Answer 24

another term for indemnity or commercial health insurance plans

Question 25

Commercial

Answer 25

another term for indemnity or traditional health insurance plans

Question 26

Government Plan

Answer 26

a health insurance plan funded by the government

Question 27

Centers for Medicare and Medicaid services (CMS)

Answer 27

a government agency that oversees the Medicare and Medicaid programs

Question 28

Medicare

Answer 28

a government health insurance plan primarily covering persons aged 65 and older

Question 29

Medicaid

Answer 29

a government plan for financially indigent people

Question 30

Medicare Part B

Answer 30

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

Question 31

Outpatient

Answer 31

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.

Question 32

Orignal Medicare

Answer 32

healthcare coverage managed by the federal government

Question 33

Carrier

Answer 33

a company that has contracted with CMS to pay Part B claims

Question 34

Fiscal agent

Answer 34

a company that contracts with CMS to pay Medicaid claims

Question 35

Eligibility Category

Answer 35

a category listing requirements for a person to be covered by a specific plan

Question 36

Manged care plan

Answer 36

a health insurance plan that includes financing, management, and delivery of health care services

Question 37

Primary Care Provider (PCP)

Answer 37

a provider (or other health care provider) who is responsible for a patients main health care

Question 38

Specialist

Answer 38

a provider who specializes in a particular area of medicine

Question 39

Prescription drugs

Answer 39

medications prescribed by a provider (or other licensed prescriber)

Question 40

Emergency room visits

Answer 40

an encounter in the emergency room

Question 41

Health Maintenance organization ( HMO)

Answer 41

a prepaid medical service plan that provides services to plan members

Question 42

In network

Answer 42

medical care sought from participating providers within a managed care plan

Question 43

Out of Network

Answer 43

medical care sought from nonparticipating providers; those providers who have not contracted with specific managed care plans

Question 44

Preferred Provider organization (PPO)

Answer 44

this type of plan offers discounts to insurance company clients in exchange for more members

Question 45

out of pocket

Answer 45

the patients share of the cost of health care services. this can include co-payments, co-insurance or an deducible

Question 46

Point- of- service (POS)

Answer 46

plan a health insurance plan in which the patient pays a co-payment when staying in network

Question 47

Medicare Advantage

Answer 47

a private company that contracts with Medicare to offer and mange a plan for Part A and Part B Medicare heath insurance benefits.

Question 48

Medicare Part C

Answer 48

plans run by private companies that combine coverage for both hospitals and provider visits for an out of pocket fee

Question 49

Referral

Answer 49

permission from the primary care provider to seek services from a specialist for an evaluation, testing, and/or treatment. managed care plans require this

Question 50

Tricare

Answer 50

Health insurance provided for retired military personals, active military personal , and their dependants

Question 51

Tricare Prime

Answer 51

the only tricare plan offering coverage for active-duty service members. retired members may also select this plan

Question 52

Military Treatment Facility (MTF)

Answer 52

a place where tricare members receive medical treatment

Question 53

Preferred Provider Network (PPN)

Answer 53

a group of civilian medical providers that has contracted with Tricare

Question 54

Tricare Standard

Answer 54

a Tricare plan available only to retired military service members and their families. this plan is available both in the United States and oversees.

Question 55

Tricare Extra

Answer 55

a Tricare plan available only to retired military service members and their families. this plan is not available oversees

Question 56

Coverage

Answer 56

existence and scope of the existing health insurance

Question 57

Individual

Answer 57

the one and only person covered under a health insurance plan

Question 58

Employee

Answer 58

a person employed who is covered under an employers group health plan

Question 59

Husband/Wife (H/W) Coverage

Answer 59

health insurance covering both the husband and wife

Question 60

Employee/Significant other (E/S) Coverage

Answer 60

health insurance covering the employee and the employees significant other

Question 61

Parent/Child coverage

Answer 61

health insurance coverage for a parent and child

Question 62

Family coverage

Answer 62

health insurance coverage for the individual employee, the employees spouse and the employees children

Question 63

Dependents

Answer 63

persons covered under the policyholders plan