Unit 3 - Lesson 2: Comprehensive Health Insurance

Question 1

Provisions stating that the insured and the insurer will share all losses covered by the policy in A proportion agreed upon in advance; for example, a 80 to20 policy means that the insurer pays 80% and the insured pays 20% of the expenses

Answer 1

Coinsurance

Question 2

In arrangement in which the covered person pays a specified amount for various services and the healthcare provider pays the remainder. The cover person usually must pay his or her share when the services rendered. is similar to coinsurance except that the coinsurance is usually a percentage of certain charge where this is fixed

Answer 2

Copayment

Question 3

Portion of an insured loss paid by the insured before he or she is entitled to benefits from the insurer; for example, a person must be required to meet a $200 deductible before receiving the insurance benefits

Answer 3

Deductible

Question 4

Health insurance provided to a group, most often a group of employees, providing coverage in the form of lump sum payment or periodic payments to compensate for income losses due to bodily injury, sickness, or disease as well as medical expenses

Answer 4

Group health insurance

Question 5

Provision of security against a hurt, loss, or damage was specific cash payments

Answer 5

Indemnity

Question 6

Party to an insurance arrangement who is secured against losses in provided benefits or services; this term is preferred to terms such as policyholder and policy owner

Answer 6

Insured

Question 7

Party to an insurance arrangement Who undertakes to indemnify for losses, provide benefits, or render services. The term is preferred to company or carrier. Also known as third-party payer

Answer 7

Insurer

Question 8

A type of health insurance that provides benefits up to a high limit for most types of medical expenses incurred, subject to a large deductible. These policies usually pay cover expenses whether an individual is in or out of the hospital

Answer 8

Major medical insurance

Question 9

Amount not covered by insurance that the covered ( or insured) person must pay out of his or her own pocket, such as coinsurance and deductible

Answer 9

Out of pocket expenses

Question 10

Any individual or group of individuals that provide a healthcare service (such as physicians or hospitals)

Answer 10

Provider

Question 11

A rate paid by managed care plans, usually monthly, to a healthcare provider. In return the provider agrees to deliver the health services agreed-upon to any person covered under the managed-care plan. The payment provided has no relationship to the type of service performed or number of services the patient receives

Answer 11

Capitation

Question 12

The method by which a physician or provider bills for each service or visit instead of on a prepaid (that is, all-inclusive) basis. This was the initial way that patients received treatment, for which they usually paid cash

Answer 12

Fee for service

Question 13

A system of healthcare where the goal is to deliver quality, cost effective healthcare through monitoring and recommending utilization and cost of services

Answer 13

Managed care

Question 14

A system where in reimbursement is made to the provider based on a predetermined reimbursement level rather than on actual charges after the service has been provided

Answer 14

Prospective payment system (PPS)

Question 15

A system where in reimbursement is made to providers after healthcare services have been given

Answer 15

Retrospective payment system

Question 16

Charges for healthcare services that are based on the physicians “usual“ charge for the service, which is the “customary“ amount that other physicians in the area charge, and a “reasonable“ amount for the service performed

Answer 16

Usual, customary, and reasonable charges (UCR)

Question 17

Contract that covers specific medical expenses for individuals or groups

Answer 17

Prepaid health plan

Question 18

Protection against income losses for illness or injury, disability income, and accidental death or dismemberment

Answer 18

Health Insurance

Question 19

Coverage for specific medical expenses

Answer 19

Medical insurance

Question 20

Healthcare providers receive payment for actual charges after healthcare services were provided

Answer 20

Fee-for-service basis

Question 21

Predetermined reimbursement level

Answer 21

Prospective basis

Question 22

Regular, pre-established amounts paid by private insurance holders

Answer 22

Premiums

Question 23

Healthcare plans that are funded and administered by the federal or state government; examples include Medicare and Medicaid

Answer 23

Government sponsored healthcare programs

Question 24

Hospital insurance coverage for those meeting Medicare criteria

Answer 24

Medicare part A

Question 25

Supplemental insurance coverage for those meeting Medicare criteria

Answer 25

Medicare part B

Question 26

Care for patients who are expected to remain in the hospital for at least 24 hours or more to receive care from a physician

Answer 26

Inpatient hospital care

Question 27

Care for persons with chronic disease or disabilities

Answer 27

Long-term care

Question 28

Care including rehabilitation, 24 hour nursing coverage, and physical occupational, and speech therapies

Answer 28

Skilled nursing facility (SNF) care

Question 29

An organization that’s primarily designed to provide pain relief, symptom management, and supportive services for the terminally ill and their families

Answer 29

Hospice care

Question 30

Expenses that aren’t covered by insurance

Answer 30

Out of pocket expenses

Question 31

A collection of inter-dependent systems that integrate the delivery of healthcare services to a specific population

Answer 31

Managed care plan

Question 32

A prepaid medical service plan that provide services to plan members

Answer 32

Health maintenance organization (HMO)

Question 33

Represent an organization of hospitals and physicians who, for a set fee, provide services to insurance company clients

Answer 33

Preferred provider organizations (PPO)

Question 34

Groups of doctors, hospitals, and healthcare providers who organize into a group to provide care to Medicare patients

Answer 34

Accountable care organization