Exam III Flashcards
Blue Cross
a group of private nonprofit companies offering insurance that reimburses individuals primarily for the cost of hospital care, not including doctors’ bills
Blue Shield
a group of private nonprofit companies offering insurance that reimburses individuals primarily for the costs of receiving care from doctors, especially care received in hospitals
Fee-For-Service
the practice of paying doctors for each health care service they provide, rather than paying them a salary
Fee-For-Service Insurance
insurance that reimburses patients for all or part of the costs of the health care services they have purchaced
Deductible
dollar amount of health care expenses an individual with some forms of health insurance must pay annually before the insurance plan will begin covering the remaining costs of health care
Preferred-Provider Organizations (PPOs)
health insurance plans in which doctors agree to charge lower, preset fees in exchange for the additional business, and consumers agree to obtain care from these doctors in exchange for lower premiums and deductibles
Community Rating
a system for calculating insurance premiums in which each individual pays a premium based on the average health risk of the community as a whole
Commercial Insurance
insurance offered by companies that function on a for-profit basis
Actuarial Risk Rating
a system in which insurers try to maximize their financial gain by identifying and insuring only those populations that have low health risks
Health Maintenance Organizations (HMOs)
organizations that provide health care based on prepaid group insurance. Patients pay a fixed yearly fee in exchange for a full range of health care services, including hospital care as well as doctor’s services
Retrospective Reimbursement
a system in which insured individuals first receive care from health care providers and pay their bills, and then their insurance provider reimburses them for all or part of these costs
Primary Care Doctors
those doctors in family or general practice, internal medicine, and pediatrics who are typically the first doctors individuals see when they need medical care–and who serve as the gatekeepers who refer patients to specialists in managed care plans such as HMOs
Copayment
fee paid by person who have certain forms for health insurance each time they see a care provider
Capitation
a system in which doctors are paid a set annual fee for each patient in their practice, regardless of how many times they see their patients or what services the doctors provide for their patients
Managed Care
a system that controls health care spending by monitoring closely how health care providers treat patients and where and when patients receive their health care
Managed Care Organizations (MCOs)
health insurance providers, such as HMOs that operate under the principles of managed care
Formulary
official list of drugs that doctors in a managed care organization can prescribe without special authorization
Medicare
federal insurance, based on the Social Security system, that offers hospital and medical coverage to those over the age 65 and to permanently disabled persons
Medigap Policies
insurance policies available for purchase by persons who receive Medicare to pay for prescription drugs and other medical services not available through Medicare
Medicaid
joint federal-state health insurance program that pays the costs of health care for people with incomes below a certain (very low) amount
