Insurance and Government Programs

Medicare

- A program funded and administered by the federal government,created for patients ages 65 or older and people with certain disabilities. -Administered By CMS -Usually available for people 65 and older,People with a disability and have received a social security benefits for at least two years,People with End Stage Renal Disease.

Medicaid

-A program administered by state governments to help people with low income and few resources secure medical care. -Funded by state and federal government. -Medicaid Eligibility must be checked before each visit to an office. -Claims processed by Fiscal intermediaries contracted by each state.

Workers Compensation

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

Manage Care

-Insurance carrier will pay the healthcare provider directly for medical services -Requires patients to choose from a specific network of providers.

Fee For Service

-Patient has greater financial responsibility -Usually does not cover preventative care -Patients choose their healthcare provider.

Four sub-models of HMO

-Staff The HMO will hire a group of physicians and pay them salary wages -IPA A network of physicians with independent practices -Group Group of physicians in the same workplace. -EPO Combines features of an HMO and a PPO, Physicians are reimbursed based on a fee-for-service system.

Workers' Compensation Insurance Covers

-physical injuries -stress -mental illness that is employment related

TRICARE Extra

A PPO type of TRICARE option; individual does not have to enroll or pay an annual fee

Carrier

A company or organization that provides health insurance.

HMO (Health Maintenance Organization)

A managed care organization that provides comprehensive medical services for a predetermined annual fee per enrollee.

POS (Point of Service)

A plan, combining features of an HMO and a PPO, in which members may choose from providers in a primary or secondary network.

PPO (Preferred Provider Organization)

A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan's network.

CHAMPVA

Civilian Health and Medical Program of the Department of Veterans Affairs

Private Funding comes from?

Enrollees

What are the levels of disability

Medical Treatment Only -Patient can return to work after treatment Temporary Disability -Patient cannot return to work until authorized by physician Permanent disability -Patient cannot return to the same line of work.

Can someone be eligible for TRICARE and CHAMPVA

No

Can you see any healthcare provider under workers compensation

No,There are designated physicians.

Capitation

System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan.

Who must employer report injuries to immediately.

The company's workers compensation insurance agent

TRICARE Standard

The fee-for-service health plan offered by TRICARE.

Medicare Part B

The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.

Benefits

What you receive as a result of being a member of an insurance company.

Medicare—Part D Prescription Drug Coverage

a United States federal-government program to subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries.

Health Insurance

a contract between a patient and a health insurance carrier that protects the patient against financial loss when in need of medical services.

Deductible

a specified amount of money that the insured must pay before an insurance company will pay a claim

Medigap policy

an insurance policy that pays for health care expenses not covered by Medicare

Medicare Part A(Inpatient)

automatic at age 65 if the person paid the premiums. if the person never paid the premiums(full time house wife) the person is not eligible for Medicare coverage) Also covers person with end stage diseases at any age. Medicare part A will pay for the following "medically necassary " services: -inpatient hospitalization(including inpatient psych) -hospice care -home health care -skilled nursing facility Medicare Part A will not pay for custodial care(nursing homes, retirement homes)

TRICARE Prime

managed care option similar to a civilian health maintenance organization (HMO).

TRICARE

military health plan that provides services for active duty personnel and their families, survivors of military personnel and retired military personnel and their families

TRICARE Select

provides fee-for-service health care option; combined TRICARE Standard and TRICARE Extra into one program. TRICARE Standard was previously called CHAMPUS.

Monthly Premium

the cost a patient pays each month for health and/or drug insurance

Coinsurance

the sharing of expenses by the policyholder and the insurance company

Medicare Part C (Medicare Advantage)

•Replaces and covers expenses found in Part A and B •Medicare private fee-for-service plans (PFFS) •Medicare managed care plans (HMOs and PPOs) •Medicare specialty plans