Government programs and insurance

TRICARE Prime

A voluntary HMO-type option for TRICARE beneficiaries,

Medicare A

Hospital services,extended care for hospitalization,home health services,hospice

preventive care

a service or procedure performed with the goal of preventing future injury or illness.Covered in order to avoid bigger more expensive problems later

workers compensation

administered by state governments and funded in part by employers to help those who are injured on the job

managed care

an approach to insurance aimed at providing affordable,high-quality healthcare while cutting cost

Health Maintenance organization (HMO)

an organized system for providing healthcare in a specific geographic area.Based on monthly premium paid by: patient,patients employer,or shared between the two

health insurance carrier

company that provides health insurance plans

Health insurance

contract between patient and a health insurance carrier

PPO

contracts with healthcare agencies to provide care at reduced rates

HMO group model

contracts with multi speciality group of physicians.These physicians usually practice in the same facility

claim

document sent to an insurance carrier billing them for services provided to an insured patinet or an insured patients beneficiary.EXP:HCFA-1500 and UB-40

HMO EPO

exclusive provider organization,combines features of an HMO and preferred provider organization.Physicians are reimbursed based on a free-for-service system

beneficiary

family member covered under same policy.To include the beneficiaries on an insurance plan,they must pay higher premiums and deductibles

medicare C

free for service plans,high-deductible insurance plans,medicare managed care plans,medical savings account plans (MSA),everything covered by A and B,preventive care,prescription costs,dental care,eye care,and hearing aids

medicare

funded partially by the federal government through tax dollars.funded by premiums by the coinsurance,administered by Centers for Medicare and Medicaid services

public funding

funding from state or federal governments

HMO IPA

independent practice association is network of physicians with independent practices

POS

insured persons must select a primary care physician,who must pre-approve visits to specialist

TRICARE

is an abbreviation for triple option care,which covers the following:active and retired military personnel and their families,surviving spouses and dependents of military personnel,spouses and dependents of military retirees

Insurance benefits

medically necessary services the insurance carrier will cover or reimburse.exp:labs and x-rays

group insurance

most commonly available through an employer,employer selects what plans are offered,employer pays a part of the premium

managed care plans

offers services through a system of healthcare providers who are contracted to provide those services at reduced rates

out-of pocket expenses

patient is responsible for the cost.EXP:Deductibles,coinsurance or copayments,exclusions

free-for-service plan

patient pay healthcare cost out of pocket.patients reimbursed by the carrier for their expenses.

birthday rule

patients whose birthday comes in the first calendar year will provide the primary policy.Birthday is based on the month and day withing the calendar year.if parents have the same birthday,policy with the earlier effective date will be primary.

individual healthcare plans

person purchases a policy,agrees to pay the entire premium,more expensive,allows for more choice

patient registration form

personal contact info,employer info,medical history.Collecting new info is the main responsibility

Medicare B

physician visits,outpatient services,physical therapy,durable medical equipment,radiology,ambulance fees,laboratory services

medicare D

prescription drugs

medicare

program administered and funded by the federal government.Created to help offset the costs of medical care for citizens age 65 or older,and other groups who have certain medical conditions or disabilities.

medicaid

program administered by state governments to help people with low income and few resources secure medical care

TRICARE Select

provides fee-for-service health care option;provides the most options and is convenient for receiving medical services nationwide

exclusion

provision within a health insurance policy that eliminates coverage for certain acts,property,types of damages,or locations

Medicare eligibility

recipients automatically receive benefits for which they are eligible.EXP:people age 65 and over,people with a disability who have received social disability benefits for at least two years,people with end-stage renal disease

workers compensation

state-administered program,employees who work for a business with 3 or more employees,coverages is a legally mandated right

medigap policies

supplement medicare by covering out of pocket charges

monthly premium

the fee patient pay to enrol in an insurance plan

enrollees

those who are enrolled in the insurance plans

HMO staff model

will hire a group for physicians and pay them salary wages