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Health Insurance
Chapter 3, 13, 14
| Question | Answer |
|---|---|
| A voluntary process that a health care facility or organization (e.g., hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law. | Accreditation |
| Also called triple option plan; provides different health benefit plans and extra coverage options through an insurer or third-party administrator | cafeteria plan |
| Provider accepts preestablished payments for providing health care services to enrollees over a period of time | capitation |
| Development of patient care plans to coordinate and provide care for complicated cases in a cost--effective manner | case management |
| health care is provided in an HMO-owned center or satellite clinic or by providers who belong to a specially formed medical group that serves the HMO | closed-panel HMO |
| review for medical necessity of tests and procedures ordered during an inpatient hospitalization | concurrent review |
| involves arranging appropriate health care services for the discharged patient e.g. home health care | discharge planing |
| also called covered lives; employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans | enrollees |
| managed care plan that provides benefits to subscribers if they receive services from network providers | exclusive provider organization (EPO) |
| reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service are provided, or if more expensive services (e.g. brand-name vs. generic prescription medication) | fee-for-service |
| prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services | gag clause |
| primary care provider for essential health care services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists | gatekeeper |
| responsible for providing health care services to subscribers in a given geographical area for a fixed fee | health maintenance organization (HMO) |
| created standards to assess managed-care systems using data elements that are collected, evaluated, and published to compare the performance of managed health care plans | Healthcare Effective Data and Information Set (HEDIS) |
| legislation | laws |
| responsible for the health of a group of enrollees; can be a health plan, hospital, physician group, or health system. | managed care organization (MCO) |
| combines health care delivery with the financing of services provided | managed health care (managed care) |
| a private, not-for-profit organization that assesses the quality of managed care plans in the United States and releases the data to the public for its consideration when selecting a managed care plan. | National Committee for Quality Assurance (NCQA) |
| physician, other health care practitioner, or health care facility under contract to the managed care plan. | network provider |
| health care provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO. | open-panel HMO |
| include payments made directly or indirectly to health care providers to serve as encouragement to reduce or limit services (e.g., discharge an inpatient from the hospital more quickly) to save money for the managed care plan. | physician incentives |
| delivers health care services using both managed care network and traditional indemnity coverage so patients can seek care outside the managed care network. | point-of-service plan (POS) |
| review for medical necessity of inpatient care prior to the patient's admission. | preadmission certification (PAC) |
| review for medical necessity of inpatient care prior to the patient's admission. | preadmission review |
| network of physicians, other health care practitioners, and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee. | preferred provider organization (PPO) |
| responsible for supervising and coordinating health care services for enrollees and preauthorizing referrals to specialists and in-patient hospital admissions (except in emergencies). | primary care provider (PCP) |
| reviewing appropriateness and necessity of care provided to patients prior to administration of care. | prospective review |
| contains data regarding a managed care plan's quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control. | report card |
| reviewing appropriateness and necessity of care provided to patients after the admini-stration of care. | retrospective review |
| enrollee who sees a non-HMO panel specialist without a referral from the primary care physician. | self-referral |
| person in whose name the insurance policy is issued. | subscribers (policyholders) |
| offered by a single insurance plan or as a joint venture among two or more third-party payers, and provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans; also called cafeteria plan or flexible benefit plan. | triple option plan |
| method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care. | utilization management (utilization review) |
| BlueCross BlueShield (BCBS) coverage for the following services: hospitalization, diagnostic laboratory services, x-rays, surgical fees, assistant surgeon fees, obstetric care, intensive care, newborn care, and chemotherapy for cancer. | BCBS basic coverage |
| office visits, outpatient nonsurgical treatment, physical and occupational therapy, purchase of durable medical equipment (DME), mental health visits, allergy testing and injections, prescription drugs, private duty nursing, | BCBS major medical (MM) coverage |
| insurance plan created in 1929 when Baylor University Hospital, approached teachers in the Dallas school district with a plan that guaranteed up to 21 days of hospitalization per year for subscribers and each dependent for a $6 annual premium. | BlueCross |
| began as a resolution passed by the House of Delegates at an American Medical Association meeting in 1938; incorporates a concept of voluntary health insurance that encourages providers to cooperate with prepaid health plans. | BlueShield |
| provides global medical coverage for active employees and their dependents who spend more than six months outside the United States; | BlueWorldwide Expat |
| pays taxes on profits generated by the corporation's for-profit enterprises and pays dividends to shareholders on after-tax profits. | for-profit corporation |
| charitable, educational, civic, or humanitarian organization whose profits are returned to the program of the corporation rather than distributed to shareholders and officers of the corporation. | nonprofit corporation |
| special contract clause stipulating additional coverage above the standard contract. | rider |
| document that acknowledges patient responsibility for payment if Medicare denies the claim | advance beneficiary notice of noncoverage (ABN) |
| begins with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days. | benefit period (Medicare) |
| enrollment period for Medicare Part B held January 1 through March 31 of each year | general enrollment period (GEP) |
| autonomous, centrally administered program of coordinated inpatient and outpatient palliative (relief of symptoms) services for terminally ill patients and their families. | hospice |
| seven-month period that provides an opportunity for the individual to enroll in Medicare Part A and/or Part B. | initial enrollment period (IEP) |
| managed care plans and private fee-for-service plans, provide care under contract to Medicare and include such benefits as reductions in out-of-pocket expenses, and prescription drugs. enrollees have the option of enrolling in one of several plans; | Medicare Advantage (Medicare Part C) |
| reimburses institutional providers for inpatient, hospice, and some home health services. | Medicare Hospital Insurance (Medicare Part A) |
| reimburses noninstitutional health care providers for outpatient services. | Medicare Medical Insurance (Medicare Part B) |
| reimburses institutional providers for inpatient, hospice, and some home health services. | Medicare Part A |
| reimburses noninstitutional health care providers for outpatient services. | Medicare Part B |
| managed care plans and private fee-for-service plans, which provide care under contract to Medicare and as coordination of care, reductions in out-of-pocket expenses, and prescription enrollees have the option of enrolling in one of several plans; | Medicare Part C |
| prescription drug coverage added to Medicare plan, some Medicare Cost Plans, some Medicare private fee-for-service plans, and Medicare Medical Savings Account Plans; Medicare beneficiaries present a Medicare prescription drug discount card to pharmacies | Medicare Prescription Drug Plans (Medicare Part D) |
| supplemental plans designed by the federal government but sold by private commercial insurance companies to cover the costs of Medicare deductibles, copayments, and coinsurance, which are considered gaps in Medicare coverage | Medicare Supplementary Insurance (MSI) |
| combination of Medicare and Medicaid programs; available to Medicare-eligible persons with incomes below the federal poverty level. | Medicare-Medicaid (Medi-Medi) crossover |
| supplemental plans designed by the federal government but sold by private commercial insurance companies to cover the costs of Medicare deductibles, copayments, and coinsurance, which are considered gaps in Medicare coverage. | Medigap |
| enables Medicare beneficiaries to participate in mass PPV (pneumococcal pneumonia virus) and influenza virus vaccination programs offered by Public Health Clinics (PHCs) and other entities that bill Medicare payers. | roster billing |
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