Ch 27 study guide

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True or False Health insurance typically covers services and procedures considered medically necessary. Most insurance policies also cover "elective" procedures, such as certain cosmetic surgeries, that are not considered medically necessary.

false

True or False There are no government managed care plans.

false

Independent practice association

general or family practice provider or provider group that practices independently and may contract with several HMOs

Medigap

if people have medicare part A and B they may choose to purchase a medigap policy, which is a medicare supplement insurance that covers the payment gaps for an individual person.

What are the services that must be covered by Medicaid in each state?

inpatient/outpatient hospital services, nursing facility services, home health services, physician services, rural health clinic service, federally qualified health center services, laboratory and x-ray services, family planning services, nurse midwife services, certified pediatric and family practitioner services, freestanding birth center services, transportation to medical care, tobacco cessation counseling for pregnant women

Participating provider

is a healthcare provider who signed a contract with an insurance company, managed care plan, or government health plan to provide services to policyholders

Self-Insured

many large companies or organizations have enough employees that they can fund their own insurance program. employer provides health or disability benefits to employees with its own funds

Services that are needed to improve the patient's current health are considered

medically necessary

Who is eligible for Medicare and Medicaid

medicare - patients who are age 65 or older, Medicaid - low income patients

Medicare A, B, D , C

medicare A - covers inpatient hospital charges, B - covers ambulatory care, including primary care and specialists, C - option for medicare qualified patients to turn their part A and B benefits into a private plan that can offers some additional benefits, D - perscriprtion drug program offered to medicare qualified individuals that requires an additional month premium

Individual policy

one that is not offered by an employer or another group

Indigent

poor, needy, impoverished

Group policy

private health insurance plan purchased by an employer for a group of employees

Insurance verification

process of confirming health insurance coverage for the patient. when medical assistant schedules an appointment, health insurance should be collected

Tricare

program for active duty and retired members of the uniformed services, their families, and survivors

Worker's compensation

publicly sponsored system that pays monetary benefits to workers who become injured or disabled in the course of their employment

The affordable care act includes?

requires all health plans to cover essential health benefits , ambulatory patient services, hospitalization, mental health and substance use disorder services, prescription drugs, preventive and wellness services and chronic disease management, emergency services, maternity and newborn car, rehabilitative and habilitative services and devices, laboratory services, pediatrics services, including oral and vision care

Utilization review

reviews individual cases to ensure that medical care services are medically necessary

What are preventive services?

services provided to help prevent certain illnesses or that lead to an early diagnosis

Co-insurance

the percentage of costs of a covered healthcare service that policyholder pays after the deductible has been paid

Premium

the periodic payment of a specific sum of money to an insurance company, for which the insurer in return provides certain benefits

Gatekeeper

the primary care provider, who is in charge of a patient's treatment, additional treatment, such as referrals to a specialist must be approved by the gatekeeper

Champva

Civilian health and medical program of the veterans administration

Beneficiary

a designated person who receives funds from an insurance policy

EOB

a document sent by the insurance company to the provider and the patient explaining the allowed charge amount the amount reimbursed for services, and the patient's financial responsibilities

Claim

a formal request for payment from an insurance company for service provided

Fee Schedule

a list of fixed fees

Capitation

a payment arrangement for healthcare providers. the provider is paid a set amount for each enrolled person assigned to them, per period of time, whether or not that person has received services

Deductible

a set dollar amount that the policyholder must pay before the insurance company starts to pay for services

Copay

a set dollar amount that the policyholder must pay for each office visit

Policy

a written agreement between two parties, in which one party agrees to pay another party if certain specified circumstances occur

Provider network

an approved list of physicians, hospitals, and other providers

Referral

an order for a primary care provider for the patient to see a specialist or to get certain medical services

Third-party administrator

an organization that processes claims and provides administrative services for another organization. often used by self funded plans

HMO

- Health maintenance organizations, health plans regulated by HMO laws that require them to include preventive care as part of their benefits package. goal of HMO is to reduce the cost of healthcare while still providing quality healthcare

Medicaid

- health program that assists low income families or individuals in paying for doctor visits, hospital stays, long term medical and custodial care costs and more.

RBRVS

- resource based relative value scale - a system used to determine how much providers should be paid for services rendered

Which MCO has the highest premiums and the lowest? -

HMOs typically have a lower premium and PPOs have a higher premium

Which managed care plans require preauthorizations for surgeries?

Managed care organization Health maintenance organization

What plans require healthcare providers to become participating providers?

PPO

The health insurance model that offers the most flexibility for patients is

PPOs and POS plans offer more flexibility than HMOs but are more expensive


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