Module 3 Flashcards
The portion of health care costs paid by the participant during the plan year before the health plan begins to pay
Deductible
The participant’s share of the cost of medical services
Coinsurance
A fixed amount paid by the participant for a health care service
Copay
A specific healthcare provider that manages the care of the participant
Primary care provider
Authorization from a PCP to receive medical care from another provider, often a specialist
Referral
The process when insurance makes a victim whole after a loss
Indemnification
The maximum a covered individual will pay during a plan year before the health plan pays 100% of the costs of service
Out of Pocket Maximum
This is also known as the allowed amount, eligible expense, payment allowance, or negotiated rate. It is generally the basic cost of a service in a geographic area
Usual, customary, or reasonable (UCR) fee
Immunizations, well-woman checks, cholesterol screenings, and teeth cleanings are what type of care?
Preventative
Independent organizations or affiliates of health insurance carriers or health provider organizations specializing in behavioral health
MBHOs
Employment-based medical plans that cover a percentage of losses for hospital, diagnostic, and physician services expenses
Indemnity Plans
Traditional, fee-for-service, and conventional plans are also known as ____________.
Indemnity Plans
A type of plan where the insurance carrier has a significant role in the oversight of health services and care.
Managed Care
A type of plan where the participant must select a primary care physician from a set network of providers who will act as a gatekeeper to all services.
HMO
A type of plan that allows for limited out-of-network services that are not dependent on a physician referral
PPO
A hybrid managed care plan that combines the HMO and PPO models. It offers in- and out-of- network access and requires a primary care provider.
Point of Service
This type of plan focuses more on catastrophic insurance and typically has a lower premium cost and a higher deductible.
HDHP
Healthcare savings plan that allows the election of a certain dollar amount (up to IRS limits made at the beginning of the plan year that will be payroll deducted on a pre-tax basis from one’s paycheck)
FSA
Employer-funded health savings accounts where the employer does not have to roll over unused contributions from year to year.
HRA
A health savings plan that can be funded by the employer and employee. Funds can be rolled over from year to year and are portable in the event employees leave the company
HSA
A rule requiring employers to offer health insurance to full-time employees as defined under the ACA or pay a penalty
Play-or-pay Mandate
A method of healthcare reimbursement to providers paid on a per-beneficiary basis
Capitation
A method of healthcare reimbursement to providers paid on a per-recipient basis
Contract Capitation
A method of healthcare reimbursement to providers paid on a per-episode basis, which can be based on diagnosis-related groups
Bundled payments
A method of healthcare reimbursement to providers paid on a per-service basis
Fee for service
Comprehensive protections against surprise medical bills from out-of-network providers for emergency services/nonemergency services at in-network facilities
No Surprises Act
Agreements that restrict or prevent insurers from making price or quality information available to patients or other third parties
Gag clauses
Coverage for mammograms & colonoscopies must be provided by group health plans subject to the ACA mandates without charging a deductible, copay, or coinsurance
Expansion of preventive services
Deductible
The portion of health care costs paid by the participant during the plan year before the health plan begins to pay
Coinsurance
The participant’s share of the cost of medical services
Copay
A fixed amount paid by the participant for a health care service
Primary care provider
A specific healthcare provider that manages the care of the participant
Referral
Authorization from a PCP to receive medical care from another provider, often a specialist
Indemnification
The process when insurance makes a victim whole after a loss
Out of Pocket Maximum
The maximum a covered individual will pay during a plan year before the health plan pays 100% of the costs of service
Usual, customary, or reasonable (UCR) fee
This is also known as the allowed amount, eligible expense, payment allowance, or negotiated rate. It is generally the basic cost of a service in a geographic area
Preventative
Immunizations, well-woman checks, cholesterol screenings, and teeth cleanings are what type of care?
MBHOs
Independent organizations or affiliates of health insurance carriers or health provider organizations specializing in behavioral health
Indemnity Plans
Employment-based medical plans that cover a percentage of losses for hospital, diagnostic, and physician services expenses
Indemnity Plans
Traditional, fee-for-service, and conventional plans are also known as ____________.
Managed Care
A type of plan where the insurance carrier has a significant role in the oversight of health services and care.
HMO
A type of plan where the participant must select a primary care physician from a set network of providers who will act as a gatekeeper to all services.
PPO
A type of plan that allows for limited out-of-network services that are not dependent on a physician referral
Point of Service
A hybrid managed care plan that combines the HMO and PPO models. It offers in- and out-of- network access and requires a primary care provider.
HDHP
This type of plan focuses more on catastrophic insurance and typically has a lower premium cost and a higher deductible.
FSA
Healthcare savings plan that allows the election of a certain dollar amount (up to IRS limits made at the beginning of the plan year that will be payroll deducted on a pre-tax basis from one’s paycheck)
HRA
Employer-funded health savings accounts where the employer does not have to roll over unused contributions from year to year.
HSA
A health savings plan that can be funded by the employer and employee. Funds can be rolled over from year to year and are portable in the event employees leave the company
Play-or-pay Mandate
A rule requiring employers to offer health insurance to full-time employees as defined under the ACA or pay a penalty
Capitation
A method of healthcare reimbursement to providers paid on a per-beneficiary basis
Contract Capitation
A method of healthcare reimbursement to providers paid on a per-recipient basis
Bundled payments
A method of healthcare reimbursement to providers paid on a per-episode basis, which can be based on diagnosis-related groups
Fee for service
A method of healthcare reimbursement to providers paid on a per-service basis
No Surprises Act
Comprehensive protections against surprise medical bills from out-of-network providers for emergency services/nonemergency services at in-network facilities
Gag clauses
Agreements that restrict or prevent insurers from making price or quality information available to patients or other third parties
Expansion of preventive services
Coverage for mammograms & colonoscopies must be provided by group health plans subject to the ACA mandates without charging a deductible, copay, or coinsurance
