Ch 27 study guide
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