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What refers to the variety of policies that can be purchased to cover certain help-related services and goods?
health insurance
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What does it mean to be insured?
covered by a policy
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Who is the individual who purchases a policy?
subscriber
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Who is the insurer?
health insurance company
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What are benefits?
covered services (services that are reimbursed by the insurance company)
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Who finances health care?
- employers
- individuals directly
- government
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What is medicare?
- federally funded
- for elderly population (65+)
- ppl with end stage renal disease
- disabled ppl who are entitled to social security
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What is medicaid?
- for indigent population
- funded by state and federal govt
- states determine eligibility, reimbursments, and specific benefit level
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What methodology requires payment after services have been rendered, called "fee-for-services", ind. or health insurer is at risk,and providers have little incentive to limit services?
retrospective
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What methodology establishes payments in advance, and the providers are paid these amounts reguardless of the costs incurred, the provider takes the risk, and contains DRGs?
prospective
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What 2 things does managed care contain?
- predetermined payment schedule,
- provider network
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What is the most restrictive health policy?
HMO (health maintenance organization)
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What insurance provides a gatekeeper who determines everything for the patient to restrict costs?
HMO
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What insurance is an open managed care model where employer negotiates lower fees in return for providing a high volume of pts?
PPO (prefered provider organization)
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What insurance offers in and out of network benefits (more coverage in network), theres an annual deductible, co-payments, and insured pays difference for out of network care?
POS (point-of-service)
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What is the evaluation of the medically necessary, appropriate, and efficient use of health care services, procedures, and facilities?
utilization review (UR)
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What is a case management?
provides monitoring and coordination of txs rendered to patients to control costs and utilization
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What is a consumer-driven health care plan?
combines employer contributions with increased employee choice and responsibility and increased health plan and provider accountability
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