Lecture 1 Flashcards
Capitation
payments made to the provider
prospectively for each member regardless of whether any healthcare was delivered. Capitation
fees are paid per month based on past claim experience for capitated population. (usually primary care based)
Fee for Service
providers are paid on a fee for
service basis or rate for service. (usually therapy/physician based)
Prospective Rate
aggregate payments for a groups
of services. Case rate payment that is all inclusive. Each service is not billed individually but bundled in one payment to the facility (per episode). (hospital, HHC, SNF’s etc)
Medicaid
provides assistance to people who cannot afford health care coverage.
Instituted for the very poor in 1965.
* Is a social welfare protection program rather than an
insurance program because enrollees must pass a test.
Medicare
Medicare pools resources and spreads financial risk associated with major medical expenses across the entire population to protect everyone.
A federal insurance program that provides health insurance to people over the age of 65, individuals who
become permanently disabled, end stage renal disease patients (ESRD), and people with ALS
Affordable Care Act of 2010
Designed to extend health coverage to those without it by expanding Medicaid, creating financial incentives for employers to offer coverage, and requiring those without employer or
public coverage to purchase insurance in newly created state
run health insurance exchanges
Medicare Part D
Provides private insurance option to allow Medicare beneficiaries to purchase subsidized coverage for the cost of prescription drugs
State Children’s Health Insurance Program (SCHIP)
Is a joint state/federal program to provide health insurance
to children and families who earn too much to qualify for Medicaid yet cannot afford to buy private insurance.
Run by individual states according to
requirements set by the federal Centers for Medicare and
Medicaid
Military Health Benefits
Provided to active duty service members, retired service
members and their dependents by the Department of Defense Military Health System
Pre-existing Condition Insurance Plan (PCIP)
Transitional program created in the Patient Protection and Affordable Care Act (PPACA)
Those eligible are US citizens or those legally residing in the US who have been uninsured for the last 6
months and have a preexisting condition or have been denied health coverage because of their condition
Managed Care Organizations (MCOS)
Integrated delivery systems aka managed care is the integration (contract) of the payer with the providers
ex. PPO, HMO, POS, EPO
HMO
- pick one primary care physician.
- All your health care services go through that doctor.
- need a referral before you can see any other health care
professional (except in an emergency). - Visits to health care professionals outside of your network
typically aren’t covered by your insurance
EPO
“Exclusive Provider Organization” plan.
* can use the doctors and hospitals within the EPO network, but
cannot go outside the network for care. There are no out-of-network
benefits
Don’t need referrals to see specialists
PPO
“Preferred Provider Organization” —-most popular plans
-allow you to visit whatever in-network physician or healthcare
provider you wish without first requiring a referral from a pcp,
encouraged to use the insurance company’s network of preferred
providers and you usually won’t need to choose a pcp
-probably have an annual deductible to pay before the insurance
company starts covering your medical bills.
* may also have a co-payment of about $10 - $30
POS
Point of Service plan
-has some of the qualities of HMO and PPO plans with benefit levels varying depending on whether you receive your care in or out of the health insurance company’s network of providers
-you may be required to designate a primary care physician who will then make referrals to network specialists
when needed. Depending upon the plan, services rendered by your PCP are typically not subject to a deductible and preventive care benefits are usually included.
* Like a PPO plan, you may receive care from non-network providers
but with greater out-of-pocket costs. You may also be responsible
for co-payments, coinsurance and an annual deductible.
