Health Insurance

Question 1

Policy

Answer 1

contract between individual/group and the insurance company

Question 2

Self-pay

Answer 2

when the person is not covered by health insurance

Question 3

policyholder

Answer 3

individual whose name the contract is in

Question 4

dependent

Answer 4

person covered under the individual’s policy

Question 5

benefits

Answer 5

services and items covered by the health insurance

Question 6

exclusions

Answer 6

things that the insurance will not cover

Question 7

pre-existing condition

Answer 7

condition that was diagnosed before the individual was covered

Question 8

medical underwriting

Answer 8

when insurance company screens applicants to find out their health status and risk factors for determining whether to insure them

Question 9

guaranteed issue

Answer 9

policy issued regardless of age, pre-existing conditions, or other factors

Question 10

coinsurance

Answer 10

percent of the cost that a patient must pay

Question 11

deductible

Answer 11

amount patient must pay before insurance company begins to pay

Question 12

copayment

Answer 12

fixed amount the patient pays for each visit

Question 13

health insurance market place

Answer 13

allows Americans to purchase health insurance according to their needs and budget

Question 14

joint commission

Answer 14

nation’s oldest and largest standards setting and accrediting body in healthcare

Question 15

cloud computing

Answer 15

network of computers working together to store and process enormous amounts of data

Question 16

write off

Answer 16

discounted amount the physician provides after all payments have been received

Question 17

accreditation

Answer 17

voluntary process an organization undergoes to demonstrate it has met standards beyond those required by law

Question 18

adverse selection

Answer 18

covering members who are sicker than the general population

Question 19

amendment to the hmo act of 1973

Answer 19

legislation that allowed federally qualified hmos to permit members to occasionally use non-hmo physicians and be partially reimbursed

Question 20

cafeteria plan

Answer 20

or triple otion plan; provides different health benefit plans and extra coverage options through an insurer or third party adminstrator

Question 21

capitation

Answer 21

provider accepts preestablished payments for providing health care services to enrollees over a period of time (usually a year)

Question 22

case manager

Answer 22

submits written confirmation, authorizing treatment, to the provider

Question 23

closed-panel hmo

Answer 23

health care provided in an HMO-owned center or satellite clinic or by providers who belong to a specially formed medical group that serves the HMO

Question 24

CMP
competitive medical plan

Answer 24

hmo that meets federal eligibili requirements for a medicare risk contract, but is not licensed as a federally qualified plan

Question 25

CDHP consumer-directed health plan

Answer 25

same as consumer-driven health plan

Question 26

CSCP customized sub-capitation plan

Answer 26

managed care plan where health care expenses are funded by insurance coverage. The individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium. Each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider (called a sub-capitation payment)

Question 27

direct contract model HMO

Answer 27

contracted health care services delivered to subscribers by individual providers in the community

Question 28

enrollees

Answer 28

covered lives; employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans

Question 29

exclusive provider organization EPO

Answer 29

managed care plan that provides benefits to subscribers if they receive services from network providers

Question 30

eqro external quality review organization

Answer 30

responsible for reviewing health care provided by managed care organizations

Question 31

federally qualified HMO

Answer 31

certified to provide health care services to medicare and medicaid enrollees

Question 32

fee for service

Answer 32

reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service are provided instead of less expensive services (brand name vs. generic prescription medication

Question 33

flexible benefit plan

Answer 33

same as cafeteria plan and triple option plan

Question 34

FSA flexible spending account

Answer 34

tax exempt account that individuals use to pay healthcare bills, also called health savings account HSA or health saving security account HSSA

Question 35

gag clause

Answer 35

prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services

Question 36

gatekeeper

Answer 36

primary care provider for essential health care services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists

Question 37

group model HMO

Answer 37

contracted health care services delivered to subscribers by participating providers who are members of an independent multispecialty group practice

Question 38

GPWW group practice without walls

Answer 38

contract that allows providers to maintain their own offices and share services (appointment scheduling and billing)

Question 39

hcra health care reimbursement account

Answer 39

tax exempt account used to pay for health care expenses; individual decides, in advance, how much money to deposit in an HCRA and unused funds are lost

Question 40

hmo health maintenance organization

Answer 40

responsible for providing health care services to subscribers in a given geographical area for a fixed fee