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
