Health Insurance Providers Vocab & Notes Chap 2B Flashcards
_____________ offer benefits to subscribers in return for the payment of a premium. Benefits are in the form of services provided by hospitals and physicians in the plan
Service providers
The dominant health insurers of the United States. The nation’s _____________________ plans are loosely affiliated through the national _____________________ Association but are independently managed. They provide the majority of their benefits on a service basis rather than on a reimbursement basis. This means that the insurer pays the provider directly for the medical treatment given to the subscriber, instead of reimbursing the insured. As participating providers, the doctors and hospitals contractually agree to specific costs for the medical services provided to subscribers. Members are known as subscribers. ___________________ plans are called prepaid plans because the subscribers pay a set fee (usually each month) for medical services covered under the plan.
Blue Cross and Blue Shield
An organization that offers comprehensive prepaid healthcare services to its members. It not only pays for healthcare in advance but also organizes and provides the services directly. Members pay a fixed fee for a range of healthcare services, from routine visits to emergencies.
The doctors and hospitals in the network deliver the care. _________ promote preventive care and may be self-funded or partner with insurance companies. Employers with 25 or more employees can offer this enrollment as part of healthcare benefits.
An HMO (Health Maintenance Organization)
A network of healthcare providers, including doctors, hospitals, and clinics, who offer services to specific groups at discounted rates. The group refers its members to these providers for healthcare services. Unlike HMOs, they usually operate on a fee-for-service basis, not prepaid. Members can choose from the set providers for their needed services. Providers are typically private practitioners who have agreed to offer services at lower fees to the group’s members. Employers, insurance companies, and health insurance providers often contract with ________. While individual members are not required to use the _________, they may receive reduced benefits if they opt for other providers.
A PPO (Preferred Provider Organization)
This program took effect in 1966. Its purpose is to provide hospital and medical expense insurance protection to those aged 65 and older. It also provides protection to any individual who suffers from chronic kidney disease or to those who are receiving Social Security disability benefits.
The federally administered Medicare program
A government program that provides disability-related benefits along with Medicare. Disability income benefits are available to covered workers who qualify under the program requirements. One of the requirements is that the individual must be so mentally or physically disabled that he cannot perform any substantial gainful work. The impairment must be expected to last at least 12 months or result in an earlier death. A five-month waiting period is required before an individual will qualify for benefits, during which time he/she must remain disabled.
Social Security OASDI program
A program under the Social Security Act that started in 1965. Its goal is to assist people in need, regardless of age, by providing federal funds to states for their medical assistance plans. Benefits are mainly for individuals with low income who are blind, disabled, or under 21 years old. These benefits can help cover Medicare deductibles and co-payment costs.
Medicaid
All states have ________________ laws and programs, which were enacted to provide mandatory benefits to employees for work-related injuries, illness, or death. Employers are responsible for providing these benefits to their employees and do so by purchasing coverage through state programs, private insurers, or by self-insuring
Workers’ compensation
A method of marketing group benefits to employers who have a small number of employees. This can provide a single type of insurance (e.g., health insurance) or a wide range of coverages (e.g., life, medical expense, and disability income insurance). An employer who wants to get coverage for employees from a ______ must first become a member of the trust by subscribing to it. A _______ may either provide benefits on a self-funded basis or fund benefits with a contract purchased from an insurance company. In the latter case, the trust (rather than the subscribing employers) is the master insurance contract holder.
Multiple Employer Trusts (METs)
A type of MET that consists of small employers who have joined to provide health benefits for their employees, often on a self-insured basis. They are tax- exempt entities. Employees that are covered are required by law to have an employment related common bond.
A multiple employer welfare arrangement (MEWA)
