Chapter 14: Basics of Health Insurance - Kinn's 13th Edition

Medically Necessary

Health insurance plans pay for health services deemed

Participating Provider

Healthcare providers need to apply to become a _______ through a process called credentialing.

Before

In the United States, healthcare practitioners render services ________ receiving payment.

a. 65 & older b. Permanent disability

List two different populations who would qualify for Medicare

Insurance market places

Low- and middle-income Americans can purchase health insurance at a(n) ___________________ to apply for health insurance and not worry about being denied for a pre-existing condition

Out of Network

Patients have a higher financial responsibility when they access care that is

Part D

Prescription drugs are covered by Medicare __________

Benefits

The amount payable by an insurance company for a monetary loss to an individual insured by that company, under each coverage, is known as

RBRVS (Resource Based Relative Value Scale)

The fee schedule designed to provide national uniform payment of Medicare benefits after adjustment to reflect the differences in practice costs across geographic areas is called the ______________

CHAMPVA (The Civilian Health & Medical Program of the Dept. of Veterans Affair)

The health benefits program run by the Dept. of Veterans Affair (VA) that helps eligible beneficiaries pay the cost of specific healthcare services and supplies is the (give acronym) ______

Third Party Administrator

The intermediary and administrator who coordinates patients and providers and processes claims for self-funded plans is called a(n) ______________

Premium

The payment of a specific sum of money to an insurance company for a list of health insurance benefits is called a(n) ________

Gatekeeper

The primary care provider who can approve or deny when a patient seeks additional care is referred to as a(n) ______________

a. Provider Work b. Charge-based professional liability expense c. Charge-based overhead

The resource-based relative value scale includes the following three parts:

Exclusion

The term for limitations on an insurance contract for which benefits are not payable is

Navigator Program

There are resources for patients who have questions on health insurance coverage through the Patient Protection and Affordable Care Act, such as

Preauthorization

is a process required by some insurance carriers in which the provider obtains authorization to perform certain procedures or services or to refer a patient to a specialist

Health Insurance

_________ is a third-party system that reimburses a provider when services are rendered for an insured patient

Indemnity Plans

_________ pay for all or a share of the cost of covered services, regardless of which physician, hospital, or other licensed healthcare provider is used. Policyholders of these plans and their dependents choose when and where to get healthcare services.

Workers Comp

___________ is an insurance plan for individuals who are injured on the job either by accident or an acquired illness

Managed Care Plan

____________ are a type of healthcare organization that contracts with various healthcare providers and medical facilities at a reduced payment schedule for their insurance members

Online Web Portal

____________ are used by many healthcare facility offices to quickly verify eligibility and benefits.

Verification of eligibility

__________________ is the process of confirming health insurance coverage for the patient for the medical service and the date of service.

J - Hospitalization F - Surgical H - Basic medical I - Major medical G - Disability A - Dental Care B - Vision Care C - Medicare supplement K - Liability Insurance D - Life Insurance E - Long-term care insurance

a. A benefits program that offers a variety of options (fee-for-service or managed care plans) that reimburse a portion of a patient's dental expenses and may exclude certain treatments. b. Provides reimbursement for all or a percentage of the cost of refraction, lenses, and frames c. Helps defray medical costs not covered by Medicare d. Provides payment of a specified amount upon the insured's death e - Covers a continuum of broad-range maintenance and health services to chronically ill, disabled , or mentally disabled individuals f - Pays all or part of a sergeon's or assistant sergeon's fees g - A form of insurance that insures the beneficary's earned income against the risk that a disability will make working uncomfortable or impossible and provides weekly or monthly cash benefits h - Pays all or part of a physician's fee for nonsurgical services, including hospital, home, and office visits i - Provides protection against especially large medical bills resulting from catastrophic or prolonged illnesses up to a maximum limit, usually after coinsurance and a deductible have been met j - Pays the cost of all or part of the insured person's hospital room and board and specific hospital services per DRG guidelines k - Often includes benefits for medical expenses related to traumatic injuries and lost wages payable to individuals who are injured in the insured person's home or in an automobile accident

TRICARE

A government-sponsored program under which authorized dependents of military personnel receive medical care was originally called CHAMPUS but now is called _____________

Group

A privately sponsored health plan purchased by an employer for their employees is considered a(n) ___________ policy

Fee-for-Service

A reimbursement model in which the health plan pays the provider's fee for every health insurance claim is called

Regular referrals

A(n) __________ usually takes 3 to 10 working days for review and approval. This type of referral is used when the physician believes that the patient must see a specialist to continue treatment

Individual Insurance

A(n) ___________ is a health insurance coverage for those who are not covered by their employer group plan.

Participating Provider

A(n) ___________ is a healthcare provider who enters into a contract with a specific insurance company or program and agrees to accept the contracted fee schedule

Self-insured Plan

A(n) ____________ __________ is funded by an organization with an employee base large enough to enable it to fund its own insurance program

Utilization Review

A(n) _____________ is a review of individual cases by a committee to make sure services are medically necessary and to study how providers use medical care resources.

HMO

A(n)_________ is a healthcare plan that controls the cost of healthcare deliver by requiring all patients to seek care with a primary care provider to assess if more specialized care is needed.

Amount Lost

Benefits cover the ___________ , or the amount that should be paid to the healthcare provider for services rendered.

TRICARE

Active duty military personnel, family members of active duty personnel, military retirees and their eligible family members under the age of 65, and the survivors of all uniformed services are covered by

Authorization

An alphanumeric number issued by the insurance company giving approval of a procedure or service is a(n)

Referral

An insurance term used when a primary care provider wants to send a patient to a specialist is a(n) ____________

Managed Care Plan

An umbrella term for healthcare plans that focus on reducing the cost of delivering quality care to patient members in return for scheduled payments and coordinated care through a defined network of primary care physicians and hospitals is

C - Medicaid A - Medicare B - Medigap

Match the following terms and definitions a. A federally sponsored health insurance program for those over 65 years or disabled individuals under 65 years old b. A term sometimes applied to private insurance products that supplement Medicare insurance c. A federally and state-sponsored health insurance programs for the medically indigent

Government

Medicaid and medicare are examples of ___________ plans

Effective Date

The _____ ______ is the date on which insurance coverage begins so that benefits are payable

Allowed amount

The ___________ is the maximum that third-party payers will pay for a procedure or service

Patient Protection & Affordable Care Act

The ______________ was passed in 2010 to assist more Americans in obtaining health insurance

Disability Income Insurance

provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury, or disease.