Module 3 Flashcards
(28 cards)
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-ofnetwork 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
Contact Ca[otatopm
A method of
healthcare
reimbursement to
providers paid on a
per-episode basis,
which can be based
on diagnosis-related
groups
Bundled payments
