130877
Description
Flashcards by Det Ferraris, updated more than 1 year ago
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Created by Det Ferraris
over 11 years ago
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| Question | Answer |
| Service type Plans | pay providers (doctors, hospitals, etc) directly for services instead of reimbursing the insured (as indemnity plans) Insureds referred to as subscribers |
| Managed Care | a broad spectrum of techniques used by health insurers to contain health care costs. |
| Gatekeeper System | System in which a PCP serves as insureds main point of contact for healthcare services and must refer an insured to see a Specialist for it to be covered. |
| Preventive Care (Wellness Benefits) | healthcare that stresses healthy behavior, regular testing, screening for diseases, and other services focused on early detection and prevention. |
| Case Management | supervising patients utilization of services to ensure that care is provided in the most cost-effective manner ex: nurse, social worker commonly used in cases of catastrophic or chronic disease |
| Capitation | a fixed monthly fee paid per insured (per head) by an insurer to a doctor for acting at the PCP for those insureds. |
| Managed care | A broad spectrum of techniques used by health insurers to contain health care costs |
| Health Maintenance Organizations (HMOs) | most restrictive, services outside of HMO network NOT covered, exception: emergency care received when HMO network not accessible. |
| HMO | copayments typical, emphasize preventive care, providers paid through capitation system, can be owned by... commecial insurers, local communitie, employers, governments, unions |
| HMOs provide both | healthcare services, healthcare coverage |
| HMO's are NOT required by law to cover prescription drugs but they usually do | HMO's are NOT required by law to cover prescription drugs but they usually do |
| Staff Model HMO | doctors are employees (staff), owns facilities |
| Group Model HMO | doctors are contractors, provide services ONLY for HMO patients |
| IPA HMO Independent Practice Association | contracts with IPAs to provide services, IPA Doctors also see non-HMO patents |
| Dual Choice Provision | required employers with 25+ to make an HMO one of the choices employees had available to them when choosing a healthcare plan |
| Blue Cross/Blue Shield | Blue Cross=hospital coverage Blue Shield=Medical coverage |
| Service-Benefit Concept | a health plan where benefits are expressed in terms of the services provided, rather than dollar maximums like in most indemnity plans |
| Pre-paid Plan | a health plan where a predetermined fee (fixed monthly premium) is paid in exchange for all services received under the plan |
| PPOs | In Network= lower deductibles, copays, coinsurance Out of Network= higher deductibles, copays and coinsurance |
| PPO Providers paid on a Fee-for-Service basis | PPO Providers paid on a Fee-for-Service basis |
| EPO Network | care MUST be received within network to be covered, providers are paid on a fee-for-service basis |
| POS Network | member only pays a minimal co-payment when services received within POS Network Members will pay higher out-of-pocket costs if services received outside of POS Network |
| Consumer Driven Health Plan (CDHP) | insurance solution in which a special tax-advantaged account is combined with a High Deductible Health Plan health savings (HSA) or Medical Savings Account (MSA) + High Deductibale Health Plan (HDHP) |
| High Deductible Health Plan (HDHP) | health insurance plan with high deductibles. required to establish HSA or MSA |
| Health Savings Account (HSA) | tax advantaged medical savings acount available for people enrolled in a HDHP. Employee is always owner of the money, Money grows tax deferred, money is invested (stocks, bonds, mutual funds, cd's, annuities), funds withdrawn for medical purposes are tax free, but nonmedical it is taxed with 10% penalty if under age of 59 1/2 |
| Medical Savings Account (MSA) AKA Archer MSA | tax advantaged medical savings account avail for people with a HDHP. Predeccesor to HSA, but still used in CA due to preferred HSA, but still used in CA due to preferred state income tax treatment. |
| Eligibility for MSA | Employee (spouse) of small employer (<50 employees) OR self-employed (spouse) |
| MSA Contributions | MSA Contributions are limited to % of the HDHP deductible. contributions can be made by either employee o employer but not at the same year. |
| Health Reimbursement Account (HRA) | employer-funded spending account that can be used by participating employees to pay for certain medical expenses determined by the employer |
| HRA | can only be established, owned, funded by employers. Employer determines contribution amounts, medical expenses covered, rollover rules. Health care plan NOT required in order to have HRA |
| Flexible Spending Account (FSA) | employer-established, tax-advantaged account FUNDED BY EMPLOYEES to pay for qualified medical expenses with tax-free dollars. UNSPENT $$ DOES NOT ROLLOVER AND IS FORFEITED TO EMPLOYER |
| Service providers pay the provider directly | Service providers pay the provider directly |
| HMO provides both healthcare services and healthcare coverage | HMO provides both healthcare services and healthcare coverage |
| HMOs have a set list of providers, and a gatekeeper (refers insureds to specialist) | HMOs have a set list of providers, and a gatekeeper (refers insureds to specialist) |
| HMOs have a set list of providers, and a gatekeeper (refers insureds to specialist) | HMOs have a set list of providers, and a gatekeeper (refers insureds to specialist) |
| HMOs used gatekeeper system that refers patients to specialists when needed. | HMOs used gatekeeper system that refers patients to specialists when needed. |
| HMO's are not required to cover Prescription Drugs | HMO's are not required to cover Prescription Drugs |
| HMOs try to minimize the use of specialty physicians | HMOs try to minimize the use of specialty physicians |
| capitation | fixed monthly fee per head (person) |
| Independent Practice Association (IPA) | Independent Practice Association (IPA) |
| HMO pays the care giver directly | HMO pays the care giver directly |
| Employer must provide DUAL CHOICE if 25+ employees | Employer must provide DUAL CHOICE if 25+ employees |
| HMOs can be owned by business organizations and commercial insurers | HMOs can be owned by business organizations and commercial insurers |
| Blue Cross & Blue Shield = PREPAID PLANS | Blue Cross & Blue Shield = PREPAID PLANS |
| Blue Cross= hospital service Blue Shield= physician service | Blue Cross= hospital service Blue Shield= physician service |
| EPO: MUST use network or you will pay fee on your own. | EPO: MUST use network or you will pay fee on your own. |
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