Busy. Please wait.
or

show password
Forgot Password?

Don't have an account?  Sign up 
or

Username is available taken
show password

why

Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.

By signing up, I agree to StudyStack's Terms of Service and Privacy Policy.


Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.

Remove ads
Don't know
Know
remaining cards
Save
0:01
To flip the current card, click it or press the Spacebar key.  To move the current card to one of the three colored boxes, click on the box.  You may also press the UP ARROW key to move the card to the "Know" box, the DOWN ARROW key to move the card to the "Don't know" box, or the RIGHT ARROW key to move the card to the Remaining box.  You may also click on the card displayed in any of the three boxes to bring that card back to the center.

Pass complete!

"Know" box contains:
Time elapsed:
Retries:
restart all cards




share
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

Health Insurance

Chapter 3, 13, 14

QuestionAnswer
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
Created by: 1250703764944304