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MAA102 Week 2 ch. 6

What is group insurance? Health insurance obtained through employment
What is another name for commerical health insurance? Private health insurance
What is any kind of health insurance paid for by someone other than the government? commerical health insurance/private health insurance
What is the one kind of commercial insurance that the government does pay for? Federal Employees Health Benefits (FEHB)
What are health insurance exchanges? Available on STATE WEBSITES, they're a set of government regulated and standardized healthcare plans from which individuals may purchase health insurance eligible for federal funding
What is the best-known commercial insurance company in the country? Blue Cross Blue Shield (BCBS)
What is designed to provide coverage for some costs that Medicare doesn't pay, ex: Medicare's deductible and coinsurance amounts? Medicare supplement plans, Medigap
What is an EOB? Explanation of Benefits is a document prepared by the carrier that gives details of how the claim was ADJUDICATED (adjudicated: make a formal judgment or decision about a problem or disputed matter)
What is managed care? A complex healthcare system in which physicians, hospitals, and other healthcare professionals organize a network.
What is a network and how does it function with managed care? An interrelated system of people and facilities that communicate with one another and work together in a unit. It coordinates and arranges healthcare services for enrollees, for the purpose of managing cost, quality, and access to healthcare.
What is an MCO? Managed care organizations set up contracts and organizations of the healthcare providers who furnish medical care to enrollees. establish list of covered benefits ties to managed care rules, and oversee healthcare they provide
What are the 2 most common types of managed healthcare? PPO and HMO
What is a PPO? Preferred provider organization; Members don't need a PCP, and don't need a referral (authorization) from a PCP, can seek healthcare outside of network for a higher copay, less laws and regulations, higher premiums
What is an HMO? Health Maintenance Organization; small copays, no deductibles, lower premiums, need a PCP, need a PCP referral to see a specialist
What is a reimbursement system in which providers receive a fixed fee for every patient enrolled, regardless of how many services used? capitation
What is a POS? point-of-service; also called "Open-ended HMO", can see providers outside of network for higher copay and higher deductible, required to choose a PCP within the network
What is a PSO? provider-sponsored organization; also called "medicare advantage plans", Medicare alternative, 51% owned and governed by providers
What 2 terms are commonly used to describe a method by which a patient is preapproved for coverage of a specific medical service, procedure, or drug? Preauthorization and precertification
What is a referral? A request by a provider for a patient to by seen and treated by another provider, usually a specialist
What is a consultation? When a PCP sends a patient to another provider to receive their opinion. The consulting provider does not treat the patient.
Created by: FindSugar