Comprehensive Health Insurance

POS plan

(point-of-service plan)—Plan in which subscribers receive care from providers within a network, but are allowed to pay a higher rate to see providers outside the network

PPO plan

(preferred provider organization)—Plan in which health care providers offer services at a discounted rate to members

"gatekeeper" concept (used in HMO's)

A Primary care physician (PCP) or another health care worker is the case manager for the patient.

Tricare

A health care program available for members of the uniformed services, their families and survivors, or others registered in the Defense Enrollment Eligibility Reporting System (DEERS). Previously known as CHAMPUS.

Primary care physician

A physician who oversees a patient's plan of care

HMO (health maintenance organization)

A prepaid medical service plan that provides services to plan members. Members must have PCP. Reimbursement is made on captivated basis (a fixed payment per patient per month)

State Children's Health Insurance Program (SCHIP)

A program that provides federal funds to states to expand Medicaid eligibility to include a greater number of uninsured children.

Capitation

A rate paid by managed care plans, usually monthly, to a health care provider. In return, the provider agrees to deliver the health services agreed upon to any person covered under the managed care plan. The payment provided has no relationship to the type of service per- formed or number of services the patient receives.

What is the Healthcare Effectiveness Data and Information Set (HEDIS)?

A set of performance measures used to compare managed care plan quality.

HEDIS (healthcare effectiveness data and information set)

A set of standardized performance measures that consumers and employers use to compare the quality of managed-care plans.

Retrospective payment system

A system wherein reim- bursement is made to providers after health care services have been given.

Prospective payment system (PPS)

A system wherein reimbursement is made to the provider based on a predetermined reimbursement level rather than on actual charges after the services have been provided.

Managed Care

A type of health care system that manages utilization, quality, and cost of services.

Out-of-pocket expenses

Amount not covered by insurance that the covered (or insured) person must pay out of his or her own pocket, such as coinsurance and deductible.

PPO (preferred provider organization)

An organization of hospitals and physicians who, for a set fee, provide services to insurance company clients. Members may choose a physical or hospital from the designated provider list.

IDS model - IPO (integrated provider organization)

An organization that manages and coordinates health care from several different providers and facilities.

IDS model - MSO (management service organization)

Businesses that provide support services, like administration, to individual physicians.

Most health care services and supplies that are medially and psychologically necessary for dependents and survivors of permanently and totally disabled veterans, survivors of veterans who died from service-related conditions, and survivors of those who died in the line of duty are covered by

CHAMPVA

Usual, customary, and reasonable charges (UCR)

Charges for health care services that are based on the physician's "usual" charge for the service, which is the "customary" amount that other physicians in the area charge, and a "reasonable" amount for the service performed.

The five coverage groups that are categorized into 25 different eligibility categories.

Children, pregnant woman, adults in families with dependent children, individuals wth disabilities, individuals 65 years and older.

CHAMPVA

Civilian Health and Medical Programs of the Department of Veterans Affairs

Who is eligible for CHAMPVA?

Dependents and survivors of permanently and totally disabled veterans.

Accrediting bodies

External evaluating organizations

Premiums

Fees that are regular, pre-established amounts paid by the insured to the insurance company who uses the money collected to pay claims submitted by others who have purchased insurance.

Managed care

Generic term for prepaid health plans that integrate financial management and delivery of health care serv- ices to control costs while also providing quality care

ACO (accountable care organization)

Groups of doctors, hospitals, and other health care providers who organize into a group to provide care to Medicare patients.

HMO model - Group model

HMO contracts with a multispecialty group to provide services (on the decline).

HMO model - IPA model (Independent or individual practice associations)

HMO contracts with an organized group of individual physicians to provide services (most predominant model)

HMO model - Network model

HMO contracts with two or more multispecialty groups to provide services.

HMO model - Staff model

HMO employs physician and health care workers directly to provide services (on the decline).

What does Medicaid provide?

Health care coverage for low-income families that meet certain eligibility requirements

IDS (integrated delivery system)

Health care networks that provide coordinated, organized, and comprehensive care to a community's population.

Integrated delivery system

Health care provider made up of several facilities provid- ing coordinated health care services

The core set of values advocated by the NCQA

Improving health care, providing accountability in health care, empowering customer by providing information, and providing excellence in customer service.

Employer-based group insurance

Insurance provided by a company for its employees

What did the Balanced Budget Act of 1997 accomplish?

It established Medicare Part .

A statements is true of major medical insurance?

It provides benefits up to a high limit for most medical expenses, subject to a deductible.

What is the purpose of integrated provider organizations (IPOs)?

Manage and coordinate health care from different providers and facilities.

Medicare Part A

Medical hospital insurance. People who meet the eligibility requirements can automatically receive without paying a premium because they or their spouses paid Medicare taxes while they were working.

EPO (exclusive provider organizations)

Medical providers, mainly physicians and a hospital, who have joined together to offer their services to specific clients. Employees or beneficiaries can obtain service only from the medical providers who are a part of the organization.

A 67 year old patient is receiving home health care for physical therapy. A medical coder would submit the bill under

Medicare Part A

Inpatient hospital care, long-term care, skilled nursing facility (SNF), home health care, hospice care are all covered under

Medicare Part A

Mrs. Fang is a 72 year old retired school teacher who has been hospitalized for pneumonia. What type of insurance is most likely being used to pay for her hospital stay?

Medicare Part A

Medically necessary Dr. services, outpatient hospital services, outpatient physical therapy, and speech pathology services are all covered under

Medicare Part B

Provides Medicare members with alternative insurance providers instead of the government. Developed to fill the void of what Medicare Part A and Part B do not cover.

Medicare Part C

A 78 year old patient is taking Lispro for diabetes and gabapentin for seizures. For these prescription medications, a medical coder would bill

Medicare Part D

Prescription Drug plan that a patient must have Medicare Part A and/or Part B to join

Medicare Part D

Medicare Part D

Medicare Prescription Drug Plan

Medicare Part B

Medicare voluntary supplemental medical insurance. Because people don't automatically receive this coverage with their Medicare. Medically necessary physician services, outpatient hospital services, outpatient physical therapy, and speech pathology services.

What supplemental insurance plan was created to provide coverage for services that aren't covered under Medicare A or B?

Medigap

NCQA

National Committee for Quality Assurance. a private, nonprofit organization dedicated to improving the quality of health care. Often referred to as the "watchdog" for the managed care industry.

IDS model - medical foundations

Nonprofit organizations that contract with physicians to manage their practices.

IDS model - PHO (physician-hospital organizations)

Organizations that provide contract health care services between hospitals and doctors, Also called "medical staff-hospital organizations."

Policyholder

Party to an insurance arrangement who is secured against losses and provided benefits or services.

Insurer

Party to an insurance arrangement who undertakes to indemnify for losses, provide benefits, or render services.

IDS model - GPWWs model (group practices without walls)

Physicians keep their own offices, but share administrative and management services with other managed care organizations.

POS (point of service)

Plans similar to HMO's combined with the concepts from the PPO model.

Health maintenance organization

Prepaid voluntary health plan that provides health care services in return for a monthly premium payment

Medicaid

Programs that provide health care coverage for low-income families who meet specific eligibility requirements.

Medicare Part C

Provides Medicare members with alternative insurance providers instead of the government, offers new beneficiary and plan enrollment systems, payment systems, appeals procedures, quality assurance, and a new national medical-education campaign to ensure that benefici- aries receive accurate information.

Indemnity plan

Provision of security against a hurt, loss, or damage with specific cash payments.

Coinsurance

Provision stating that the insured and the insurer will share all losses covered by the policy in a proportion agreed upon in advance. For example, an 80-20 policy means that the insurer pays 80 percent and the insured pays 20 percent of expenses.

Indian Health Service (IHS)

Service who's goal it is to assure that comprehensive, culturally acceptable personnel and public health services are available to American Indian and Alaska Native people. Part of the DHHS. Only for members of federally recognized Indian tribes and their descendants.

Authorized medical visits and prescription (that don't require any deductibles, premiums, or copays), Preventative care and First-priority at all military treatment facilities are benefits for active or retired military personnel and their dependents that are covered by

TRICARE

Patients registered in the Defense Enrollment Eligibility Reporting System (DEERS) are eligible for

TRICARE.

Fee-for-service

The method by which a physician or provider bills for each service or visit instead of on a pre- paid (that is, all-inclusive) basis. This was the initial way that patients received treatment, for which they usually paid cash.

PCP (primary care physician)

The physician responsible for overseeing and coordinating all aspects of a patient's medical care.

Medicare out-of-pocket expenses.

Those expenses that are not covered by Medicare that patients must pay themselves.

True or False: If you're eligible for TRICARE, you can't be eligible for CHAMPVA

True

Accreditation

When a health care organization is evaluated and undergoes an examination of its policies, procedure, and performance by an external organization to ensure that it's meeting predetermined criteria.

Ralph is assigning diagnosis and procedure does for a 35 year old patient from New Mexico, who has hypertension and end-stage renal disease. Would the patient quality for medicare?

Yes, because the patient has end-stage renal disease.

A health plan organization receives NCQA accreditation by undergoing a survey regarding specific standard based on

access and service, qualified providers, staying healthy, getting better, ad living with a illness.

Medicare Part A covers inpatient hospital care and long-term care when these services

are medically necessary.

EPOs are usually developed and implemented by

employer groups who are trying to control costs.

Skilled nursing facility (SNF) care

includes rehabilitation, 24-hour nursing coverage, and physical, occupational, and speech therapies. Covered by Medicare Part A

A provider is classified as an

individual or group of individuals that provide a health care service.

Home health agency

is a certified facility approved by a health plan to provide home health care services under contract. Covered by Medicare Part A

Medigap Insurance

is a health insurance plan that fills the "gaps" in Medicare plan coverage. It covers the services that aren't covered by the Medicare options.

Hospice care

is a organization designed to provide pain relief symptom management, and supportive services for the terminally ill and their families. Covered by Medicare Part A

Managed care plan

is a plan that involves financing, managing, and delivery of health care services. Usually a group of providers.

Home health care

is care received at home as part-time skilled nursing care, speech therapy, physical or occupational therapy, or part-time services of home health aides. Can include housework or other daily chores the the patient can no longer perform. Covered by Medicare Part A

Inpatient hospital care

is for patients who are expected to remain in the hospital for a least 24 hours or more to receive treatment from a physician. Covered by Medicare Part A

Long term care

is for persons with chronic disease or disabilities (that persist for a long period or for the rest of the person's life). Covered by Medicare Part A

Businesses that provide support service to individual physicians are called

management service organizations.

Medically needy

means that persons would be eligible for Medicaid because they have high medical expenses, except their income is above the eligibility level set by their state. Not offered by all states.

Categorically needy

means that the person and/or dependents fall into a Medicare eligibility category.

Physician-hospital organizations (PHOs) are also called

medical staff-hospital organizations.

The an HMO contracts with two or more specialty groups to provide services, this is called a

network model.

Another name for an "open-ended HMO" is a

point-of-service plan (POS).

QA

quality assurance, aka quality management

The 2 Medicaid eligibility groups are

the categorically needy and the medically needy.

If you have 80-20 policy coverage, it means

the insurer pay 80% of the expenses and you pay 20%.