Hl Flashcards
Injured
Offers comprehensive prepaid health care services its subscribing
Hmo
Subscribers pay a fixed periodic fee
Hmo
Pays a fixed periodic fee
Hmo
What is a hmo
Health maintenance organization
Payment given to physician is called
Capitation
Stressing preventive care
Hmo
Self funded based on dues or fees from their subscribers contact excess insurance
Hmo
Employers with 25 or more
Hmo
What is a ppo
Preferred provider organization
Collection of health care providers at prearranged discounts
Ppo
Fee for service rendered
PPO
Fee for service rendered
PPO
Specialize in one or more types of medical expenses and disability income insurance
Commercial insures
● Life insurance
● casualty
● monoline
Functions on the reimbursement apporach
Life insurance
Casualty
Monoline
Let’s policyholders assign benefits payments from insurer directly to health care providers
Assignment
What relieves the policy owners of first having to pay the medical care providers
Assignment
Delivers health services at its own local health care facilities subscribers
HMO
pay a fixed periodic fee
HMO
Physician that work out of the HMO facility
CLOSED PANEL
Physician who work out of their own facilities participate in hmo part time
HMO IPA
requre subscribers to select a primary care
HMO
Groups at prearranged discount prices
PPO
made in 1966 provide hospital and medical expense
MEDICARE
What’s part A
drug administration Insured enters a hospital benefit 100 days period in a skilled nursing 1-20% 21-100 flat dollar amount per day 190 days inpatient psychiatric Primary source of financing federal payroll self employment taxes
Jan1 mar31 funded by General tax revenue and user premiums
Part B
Covers inpatient hospital stay
PART A
Financial protection against the cost of medical care for accidents and illness
MEI
Excludes cove6 for care provided in a government facility written for a term of 1 yr
MEI
First dollar insurance
BMEP
Covers hospital room and board miscellaneous expenses
Part A
Expenses are covered while the insured is confined in a hospital
PART A
No deductible room board are set specified dollar amount per day up to # days
PART A
Utilization review that takes place on site length of stay in the hospital
Concurrent review
testing reducing length of hospitalization
Peradmission
Pays service is performed in or out of hospital
Basic surgical expense
Surgeon fee anestigist operating room
Basic surgical expense
Assigned a dollar amount by the insurer
Surgical schedule
Paid in full surgical expenses compared to what is deemed reasonable
Reasonable customary
Charges are the maximum amount the insurer will consider eligible for reimbursement
Usual customary reasonable UCR
Set of units is aggigned dollar per units conversion factor to determine the benefit
Relative value approach
Covers er accidents benefits offer only limited benefits they’re subject to
time limitations
Basic physician expense coverage
Supplement to a basic plan or as a comprehensive stand alone plan
Major medical expense
Benefits are 1 yr
Carry deductible coinsurance requirements
Have large benefits maximum
Covers inpatient and outpatient hospital expenses
Major medical expenses
Pain management home based services counseling hospice benefits
Major medical expenses
Lists if drugs covered by a pharmacy
Drug formulary
Initial stated dollar amount
Flat
Covers the gap between basic coverage and major medical
Corridor
Major medical plan is supplementing basic coverage
Integrated
Insured must satisfy a deductible for each accidental or illness
Per cause deductible
Insured only has to meet the deductible amount once during the benefit period
All cause deductible
Deductible begins January 1st ends dec31st insured must pay a specific
Sum out of pocket before any benefits are paid in a yr
Calendar year deductible
Permission expenses incurred during the 3 last 3 months
carried over into a new year to satisfy deductible for next year
Carry over
One deductible need be satisfied when 2 or more insured same
Family are injured in same accidents same illness
Common accident or sickness
Waives the deductible for family members after some deductible have been paid same year
Family maximum
Sharing of expenses by the insured and the insurer
COINSURANCE
Percentage of payment
Insured is 20%
Insurance companies 80%
Limits the amount of expenses the insured may be exposed to in a year
Stop loss
Taxable 20% penalty distribution
HSA
Tax advantage reimburse employees for out of pocket medical expenses and individuals
Health premiums
Health reimbursement arrangements HRA
Unused amounts maybe carried forward for reimbursement in future yrs
Hra
Reimbursement tax free qualified medical expenses or qualified
Medical plan
Hra
Employees don’t contribute to an
HRA
Small employers pay for their medical care expenses self employed
Medical saving account MSA
