Module 3 Flashcards
The portion of health care costs paid by the participant during the plan year before the health plan begins to pay
Deductible
The participant’s share of the cost of medical services
Coinsurance
A fixed amount paid by the participant for a health care service
Copay
A specific healthcare provider that manages the care of the participant
Primary care provider
Authorization from a PCP to receive medical care from another provider, often a specialist
Referral
The process when insurance makes a victim whole after a loss
Indemnification
The maximum a covered individual will pay during a plan year before the health plan pays 100% of the costs of service
Out of Pocket Maximum
This is also known as the allowed amount, eligible expense, payment allowance, or negotiated rate. It is generally the basic cost of a service in a geographic area
Usual, customary, or reasonable (UCR) fee
Immunizations, well-woman checks, cholesterol screenings, and teeth cleanings are what type of care?
Preventative
Independent organizations or affiliates of health insurance carriers or health provider organizations specializing in behavioral health
MBHOs
Employment-based medical plans that cover a percentage of losses for hospital, diagnostic, and physician services expenses
Indemnity Plans
Traditional, fee-for-service, and conventional plans are also known as ____________.
Indemnity Plans
A type of plan where the insurance carrier has a significant role in the oversight of health services and care.
Managed Care
A type of plan where the participant must select a primary care physician from a set network of providers who will act as a gatekeeper to all services.
HMO
A type of plan that allows for limited out-of-network services that are not dependent on a physician referral
PPO
A hybrid managed care plan that combines the HMO and PPO models. It offers in- and out-of- network access and requires a primary care provider.
Point of Service
This type of plan focuses more on catastrophic insurance and typically has a lower premium cost and a higher deductible.
HDHP
Healthcare savings plan that allows the election of a certain dollar amount (up to IRS limits made at the beginning of the plan year that will be payroll deducted on a pre-tax basis from one’s paycheck)
FSA
Employer-funded health savings accounts where the employer does not have to roll over unused contributions from year to year.
HRA
A health savings plan that can be funded by the employer and employee. Funds can be rolled over from year to year and are portable in the event employees leave the company
HSA
A rule requiring employers to offer health insurance to full-time employees as defined under the ACA or pay a penalty
Play-or-pay Mandate
A method of healthcare reimbursement to providers paid on a per-beneficiary basis
Capitation
A method of healthcare reimbursement to providers paid on a per-recipient basis
Contract Capitation
A method of healthcare reimbursement to providers paid on a per-episode basis, which can be based on diagnosis-related groups
Bundled payments
