Managed Health Care Flashcards
accreditations
voluntary process that a health care facility or organization (e.g., hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law.
adverse selection
covering members who are sicker than the general population.
Amendment to the HMO Act of 1973
legislation that allowed federally qualified HMOs to permit members to occasionally use non-HMO physicians and be partially reimbursed.
cafeteria plan
also called triple option plan; provides different health benefit plans and extra coverage options through an insurer or third-party administrator.
capitation
provider accepts preestablished payments for providing health care services to enrollees over a period of time (usually one year).
case manager
submits written confirmation, authorizing treatment, to the provider.
closed-panel HMO
health care is provided in an HMO-owned center or satellite clinic or by providers who belong to a specially formed medical group that serves the HMO.
competitive medical plan (CMP)
an HMO that meets federal eligibility requirements for Medicare risk contract but is not licensed as a federally qualified plan.
consumer-directed health plan (CDHP)
see consumer-driven health plan
customized sub-capitation plan (CSCP)
managed care plan in which 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).
direct contact model HMO
contracted health care services delivered to subscribers by individual providers in the community.
enrollees
also called covered lives; employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans.
exclusive provider organization (EPO)
managed care plan that provides benefits to subscribers in they receive services from network providers.
external quality review organization (EQRO)
responsible for reviewing health care provided by management care organizations.
federally qualified HMO
certified to provide health care services to Medicare and Medicaid enrollees.
fee-for-service
reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service and provided, or if more expensive services are provided instead of less expensive services (e.g., brand names vs. generic prescription medication)
flexible benefit plan
see cafeteria plan and triple option plan
flexible spending account (FSA)
tax-exempt account offered by employers with any number of employees, which individual use to pay health care bills; participants enroll in a relatively inexpensive, high-deductible insurance plan, and a tax-deductible savings account is opened to cover current and future medical expenses; money deposited I and earned) is tax-deferred, and money can be withdrawn from purposes other than health care expenses after payment of income tax plus a 15 percent penalty; unused balances “roll over” from the year to year, and if an employee changes jobs, the FSA can continue to be used to pay for qualified health care expenses; also called health savings account (HSA) or health savings security account (HSSA).
gag clause
prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.
gatekeeper
primary care provider for essential health care services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists.
group model HMO
contracted health care services delivered to subscribers by participating providers who are members of an independent multispecialty group practice.
health maintenance organization (HMO)
responsible for providing health care services to subscribers in a given geographical area for a fixed fee.
Health Maintenance Organization (HMO) Assistance Act of 1973
authorized grants and loans to develop HMOs under private sponsorship; defined a federally qualified HMO as one that has applied for, and met, federal standards established in the HMO Act of 1973; required most employers with more than 25 employees to offer HMO coverage is local plans were available.
health reimbursement arrangement (HRA)
tax-exempt accounts offered by employers with 50 or more employees; individuals use HRAs to pay health care bills; HRAs must be used to qualified health care expenses, require enrollment in a high-deductible insurance policy, and can accumulate unspent money for future years; if an employee changes jobs, the HRA can continue to be used to pay for qualified health care expenses.
health savings account (HSA)
see flexible spending account
health savings security account (HSSA)
see flexible spending account
Healthcare Effectiveness Data and Information Set (HEDIS)
created standards to assess managed-care systems using data elements that are collected, evaluated, and published to compare the performance of managed health care plans.
