NHIS and Home-Based Records Flashcards
(52 cards)
Health Insurance scheme can be defined as a system of _________ financing (pre-payment) of health expenditure through _________, _________ or _________ paid into a common pool to pay for all or part of health services specified by a policy or plan.
advance
contributions ; premiums ; taxes
Health Insurance can be broadly categorized as _________ or _________ health insurance.
social
private
Capitation: Payment to a _________________ by ____________ on behalf of a contributor for services to be rendered by provider
Fee for service: Payment made by ________ to _______________________ on referrals.
primary healthcare provider
HMOs ; HMOs
secondary/tertiary provider
Per diem: Payment made by _____________ and __________ to __________________ for _______ during admissions
Co-payment: Payment made by _________ to ___________ provider
primary providers ; HMO
secondary/tertiary provider ; bed space
enrollee ; pharmacy provider
Co-insured: Part-payment made by ________ for ________/________ under _______________ list while _____\ pays the balance
enrollee
treatment/investigations
partial exclusion list
HMO
Capitation is a health insurance payment system where a _____________ is paid a set amount per ________ for a specific period of time.
The provider is paid this amount regardless of _________________________________.
healthcare provider
patient
whether the patient receives treatment.
How Capitation works
A ____________ and a ____________ agree to a capitated contract.
The provider is paid a fixed amount per patient each month.
The amount is calculated based on the average use of healthcare services in
the area.
The payment is fixed for the year, regardless of how often the patient needs services.
health insurance company
medical provider
Why Capitation is used
Capitation is intended to __________________ of healthcare.
It can be beneficial for ______ and IPAs (____________)
reduce the high cost
HMOs
Independent Practice Ass.
HMOs are groups of health insurance providers that offer medical care. HMO members choose a _________________________ who must provide ________ for the HMO to cover medical expenses.
primary care physician (PCP)
referrals
Fee-for-service (FFS) is a health insurance payment model where providers are paid for _____________ they deliver. This model assumes that each service has a set cost, which is then billed to the patient or their insurer.
each service
How Fee-for-service (FFS) works
Providers create a ________ for the services they performed on a patient. The bill is sent to the ______________.
The insurer pays the provider for the services.
bill
patient’s insurer
What Fee-for-service (FFS) covers:
_________,__________,___________, and __________
consultations, examinations, procedures, and tests.
What Fee-for-service (FFS) means for providers
Providers are paid for each service they perform, regardless of the quality of care.
What it means for patients
The more services a provider performs, the more they are reimbursed.
Patients are billed for the services they receive.
What it means for insurers
Insurers pay providers for the services their patients receive.
Yes
Yes
Yes
Challenges of FFS
• FFS has been criticized for incentivizing ___________ of services.
• FFS has been criticized for focusing on ________ over _______ of care.
•FFS can make it difficult to treat some conditions using unconventional methods.
overutilization
Quantity; quality
A deductible is the set amount of money you ________________ for covered services per plan year before _________________________ .
A copay is also a set amount of money, but it’s a fixed fee attached to certain covered services.
pay out of pocket
your insurance starts to share costs
Copays often do not count towards the
deductible
T/F
T
meaning you pay them regardless of whether you’ve met your deductible.
Coinsurance:
Percentage of Costs: Coinsurance is a __________ of the total cost of a covered medical service that you are responsible for paying.
percentage
Coinsurance only applies after _________________________
after you’ve met your deductible
Copays are a _________ for a specific service.
Coinsurance is a _________ of the cost of a service you pay after _______________
flat fee
percentage
meeting your deductible.
Copay VS coinsired
Timing:
Contribution towards deductible
May or may not apply befire deductible; after deductible
Does not count towards it; counts towards it
Objectives of NHIS
a) Ensure that every nigerian has _________ to good healthcare services
b) Protect families from the financial hardship of _______________
c) Limit the ______ in the _______ of healthcare services
d) Ensure __________ distribution of healthcare costs among different income groups
e) Maintain ______ standard of healthcare delivery services within the scheme.
access ; huge medical bills
rise ; cost ; equitable
high
Objectives of NHIS
f) Ensure _________ in healthcare services
g) Improve and harness private sector
___________ in the provision of healthcare services
h) Ensure adequate __________ of health facilities within the federation
i) Ensure equitable patronage of all levels of healthcare
j) Ensure the ___________________ to the health sector for improved services.
efficiency; participation
distribution
availability of funds
PROGRAMMES OF NHIS
- ___________ SECTOR SOCIAL HEALTH INSURANCE PROGRAMMES
- ___________ SECTOR SOCIAL HEALTH INSURANCE PROGRAMMES
- ___________ GROUP SOCIAL HEALTH INSURANCE PROGRAMME
FORMAL
INFORMAL
VULNERABLE
FORMAL SECTOR SOCIAL HEALTH INSURANCE PROGRAMMES
a)________ Sector (Federal, States and Local Governments)
b)_______________ Sector
c) Armed Forces, Police and Other ____________ Services
d) Students of __________________ -TISHIP
Public
Organized Private
Uniformed
Tertiary Institution Social Health Insurance Programmes
