1. What is an insrance carrier?
  2. a company which provides insurance plans
  3. Health Insurance Contract
  4. The agreement between a patient and an insurance
    • carrier is that if a patient needs health services, the carrier
    • will pay a portion of the costs.
  5. Premium
  6. It is the fee patients pay to be enrolled in an insurance plan
  7. Policy
  8. states the terms of the insurance contract.
    • the patient receives benefits, or reimbursements
    • for specified services.
  9. insured
  10. The patient entering into the contract is called
  11. beneficiaries
  12. If the insured wishes to extend coverage to family members under
    the same policy, they are called
  13. out-of-pocket payments
  14. Even with health insurance, patients still must pay some fees
    • themselves. These expenses are called out-of-pocket payments.
    • (Deductibles, Coinsurance or co-payments, Exclusions)
  15. Deductible
    a fixed amount of money the patient must pay for health care before the carrier will begin to pay out benefits. and paid annually.
  16. Coinsurance
    • a fixed percentage of the cost of service. Insurance will take responsibility for 80 percent of the cost. The patient must pay the
    • remaining 20 percent.
  17. Co-payment
    a set fee collected at the time of service and are the same every time.
  18. Exclusions
    services not covered by the insurance policy. Benefits cannot be received on excluded services. Patients must pay out-of-pocket.
  19. Individual Insurance
    • when a person purchases a policy and agrees to pay the entire premium for
    • health coverage. While it is more expensive, this type of enrollment allows for more choice.
  20. Group Insurance
    most commonly purchased through an employer. Often, the employer will pay a part of the premium. Insurance is an important benefit of employment.
  21. fee-for-service plan
    may also be referred to as an indemnity plan or traditional insurance. The patients often pay health care costs out-of-pocket. Then they are reimbursed by the carrier for their expenses. Does not include preventive care. Funded privately.
  22. Managed Care
  23. The goal is to reduce the cost of medical
    • expenses. encouraging enrollees to maintain ahealthy lifestyle. offers services through a system ofhealth care providers who are contracted to provide those services at
    • reduced rates. Funded Privately.
    • must receive treatment from physicians within this system in order to
    • get the reduced cost.
  24. Medicare
    • a program administered and funded by
    • the federal government. It was created to help offset the costs of medical care for the country's senior citizens. It has also extended to other groups who have certain medical needs, such as disabled
    • individuals.
  25. Medicaid
    • a program administered by state
    • governments, but funding is shared by the federal and state governments. This program helps those under a certain income level
    • receive medical care.
  26. Workers' Compensation
  27. is administered by the state government and funded in part by employers. It helps those who are injured on the job. Patients receive both medical care and some wage reimbursement.
  28. Health Maintenance Organization (HMO)
    an organized system for providing health care in a specific geographic area. Membership in this organization is based on a monthly premium. This premium can be paid by the patient or the patient's employer, or it can be shared between the two.
  29. Capitation
    Under an HMO contract, physicians and hospitals generally receive reimbursement by,                    , which means that they are paid a specific amount per enrollee no matter how much or how little service is provided.
  30. Staff Model -HMO
    • the HMO will hire a group of physicians
    • and pay them salary wages. This is, in effect, their reimbursement for treating patients. These physicians may receive bonuses based on cost savings or the number of patients they treat.
  31. Group Model-HMO
    the HMO contracts with a multi-specialty group of physicians. These physicians usually practice in the same facility, like a hospital or group office.
  32. Independent Practice Association (IPA)
    • is a network of physicians with
    • independent practices. They do not practice in the same facility, but they are still considered part of one network.
  33. Exclusive Provider Organization (EPO)
    combines features of an HMO and a Preferred Provider Organization (PPO). While it will not reimburse patients for service obtained outside the HMO network, physicians are reimbursed based on a fee-for-service system instead of capitation.
  34. Preferred Provider Organization (PPO)
    • contract with health care agencies to provide care at reduced rates. Enrollees may visit out-of-network providers, but the out-of-pocket expenses will be higher. Unlike HMOs, PPOs do not reimburse by capitation
    • but on a fee-for-service basis.
  35. Point of Service (POS) plan
    • plans are often considered a type of
    • HMO.  developed into their own division of medical coverage. Insured persons must select a primary care physician (PCP), who must pre-approve visits to specialists.
    • But specialists may be non-network physicians. coverage may be limited for a non-network physician. subscribers may visit non-network physicians if they are willing to pay a higher co-payment and deductible.
    • for in-network services, there is no deductible and co-payments are very low.
  36. Pre-authorization
    may be required before a patient can receive certain types of treatment. Some examples include inpatient hospitalization and certain diagnostic tests. helps to control costs. It aims to ensure eligibility and medical necessity before treatment.
Card Set
health insurance info