chapter 3 managed health care Flashcards
ACCREDITATION
VOLUNTARY PROCESS THAT A HEALTH CARE FACILITY OR ORGANIZATION UNDERGOES TO DEMONSRTRATE THAT IT HAS MET STANDARDS BEYOND THOSE REQUIRED BY LAW
ADVERSE SELECTION
COVERING MEMBERS WHO ARE SICKER THAN THE GENERAL POPULATION
AMENDEMENT TO THE HMO ACT OF 1973
LEGISLATION THAT ALLOWED FEDERALLY QUALIFIED HMO’S TO PERMIT MEBERS TO OCCASIONALLY USE NOT HMO PHYSICIANS AND BE PARTIALLY REIMBURESED
CAFETERIA PLAN
PROVIDES DIFFERENT HEALTH BENFIT PLANS AND EXTRA COVERAGE OPTIONS THRUGH AN INSURER OR THIRD PARTH ADMINISRATOR
CAPITAATION
PROVIDER ACCEPTS PREESTABLISHED PAYMENTS FOR PROCIDING HEALTH CARE SERVICES TO ENROLLEES OVER A PERIOD OF TIME
CASE MANAGER
SUBMITS WRITTEN CONFIMATION AUTHORIZING TREATMENT TO THE PROVIDER
CLOSED PANEL HMO
HEALTH CARE IS PRIVIDED IN AN HMO OWNED CENTER OR SATELLITE CLINIC OR BY PROVIDERS WHO BELONG TO A SPECIALLY FORMED MEDICAL GROUP THAT SERVES THE HMO
COMPETITIVE MEDICAL PLAN
HMO THAT MEETS FEDERAL ELIGIBILITY REQUIREMENTS FOR A MEDICARE RISK CONTRACT BUT IS NOT LICENSED AS A FEDERALLY QUALIFIED PLAN
CONSUMER DIRECTED HEALTH PLAN
COSNSUMER DRIVEN HEALTH PLAN
CUSTOMIZED SUB CAPITATION PLAN
MANAGED CARE PLAN IN WHICH HEALTH CARE EXPENSES ARE FUNDED BY INSURANCE COVERAGE THE INDIVIDUAL SELECTS ONE OF EACH TYPE OF PROVIDER TO CREATE A CUSTOMIZED NETWORK AND PAYS THE RESULTING CUSTOMIZED INSURANCE PREMIUM
DIRECT CONTRACT MODEL HMO
CONTRACTED HEALTH CARE SERVICES DELIVERED TO SUBSCRIBE BY INDIVIDUAL PROVIDERS IN THE COMMUNITY
ENROLLEES
ALSO CALLED COVERED LIVES EMPLOYEES AND DEPENDENTS WHO JOIN A MANAGED CARE PLAN
EXCLUSIVE PROVIDER ORGANIZATION EPO
MANAGED CARE PLAN THA TPROVIDES BENFITAS TO SUBSCRTIBES IF THEY RECEIVE SERVICES FORM NETWORK PROVIDERS
EXTERNAL QUALITY REVIEW ORGANIZATION
RESPONSIBLE FOR REVIEWING HEALTH CARE PROVIED BY MANAGED CARE ORGANIZATIONS
FEDERALLY QUALIFIED HMO
CERTIFIED TO PROVIDE HEALTH CARE SERVICES AND MEDICARE AND MEDICAID ENROLLEES
FEE FOR SERVICE
REIMBURSEMNET METHODOLOGY THAT INCREASES PAYMENT IF THE HEALTH CARE SERVICE FEES INCREASE
FLEXIBLE BENEFIT PLAN
CAFETERIA PLAN
FLEXIBLE SPENDING ACCOUNT FSA
TAX EXEMPT ACCOUNT OFFERED BY EMPLOYERS WITH ANY NUMBER OF EMPLOYEES WHICH INDIVIDUALS USE TO PAY HEALTH CARE BILLS
GAG CLAUSE
PERVENTS PROVIDERWS FORM DISCUSSING ALL TREATMENT OPTIONS WITH PATIENTS
GATEKEEPER
PRIMARY CARE PROVIDER FOR ESSENTIIAL HEALTH CARE SERVICES AT THE LOWEST POSSIBLE COST
GROUP MODLE HMO
CONTRACTED HEALT CARE SERVICES DELIVERED TO SUNSCRIBERS BY PARTICIPATING PROVIDERS
GROUP PRACTICE WITHOUT WALLS
CONTRACT THAT ALLOWS PROVIDERS TO MAINTAIN THEOIR OWN OFFICES AND SHARE SERVICES
HEALTH CARE RIMBURSEMENT ACCOUNT
USED TO PAY FOR HEALTH CARE EXPENNSES
HEALTH MAINTENANCE ORGANIZATION HMO
RESPONSIBLE FOR PROVIDINGN HEALTH CARE SEVICES SUBSCRTIBERS IN A GIVEN GEOGRAPHIVCAL AREA
HEALTH MAINTENCE ORGANIZATION ASSISTANCE ACT OF 1973
GRANTS AND LOANS TO DEVELOP HMOS A
ONE THA THAS APPKIED OFR AND MET FEDERAL STANDAREDS
HEALTH REIMBURSEMENT ARRANGEMENT
OFFERED BY EMPLOYERS WITH 50 OR MOREEMPLOYEES
HEALTH SAVINGS ACCOUNT
FLEXIBLE SPENDING ACCOUNT
HEALTH SAVINGS SECURITY ACCOUNT
FLEXIBLE SPENDING
HEALTHCARE EFFECTIVENESS DATA ADN INFORMATION SET
STANDARDS TO ASSESS MANGED CARE SYSTEMS USING DATE ELEMENTS THAT ARE COLLEDCTED