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Health Insurance


Autonomy working w/o direct supervision
covered entity anhyone who provides treatment, payment, or operations in healthcare
diagnosis reason patient seeks medical health
Electronic data interchange (EDI) computer to computer exchange of structured info
trading partners any business entity engaging EDI
CMS-1500 Standard insurance form used by all gov and most commercial insurance (3rd party) payers ; new version of HIPAA’s standard for filing electronic claims ;
NUCC established this Software used to submit claims must meet the electronic filing
HIPAA created this opportunity for healthcare to move from paper transactions to electronic transactions thus creating jobs
CMS mandates this that insurance claims are to be submitted electronically and by paper with exceptions
Accountable Care Organization (ACO) intention to provide a more efficient way to deliver care, network of dr’s & hospitals that shares responsibility for providing care to patients, agree to manage all healthcare needs of a min of 5000 Medicare beneficiaries for at least 3yrs
Affordable Care Act (ACA,PPACA) provides numerous rights and protections that make health coverage’s more fair and easy to understand, subsidies to make it more affordable (premium tax credits & cost sharing reductions), expands Medicaid to cover more people with low incomes
Annual dollar limit cap put on insurance benefits while enrolled on the plan for the year after the cap has been reached patient will pay for all costs for the remainder of the year
balance billing when a provider bills you for the difference between the providers charges and the allowed amount
providers charge is $100 & the allowed amount is $70, the provider may bill the patient $30. this is an ex of? balance billing
birthday rule informal procedure to determine primary coverage, applies to children and the disabled; it states that the parent of whose birthday falls first on the calendar year will be considered the primary plan
cafeteria plan reimbursement plan by the IRS allowing employees to contribute a certain amount of their gross income to a designated account(s) before taxes are calculated
capitation fixed amount of money paid to the provider per patient per unit of time
If an insurer negotiates to pay a health care provider $300/ yr for 1000 people enrolled in a plan this is a capitation reimbursement model
Civilian health and medical program of the department of veteran affairs (CHAMPVA) health program where the VA shares the cost of certain healthcare services and supplies with eligible beneficiaries
CMS-1500 claim form universal form created by the government for Medicare claims and has been adopted by 3rd parties. It can be submitted electronically or in paper w/ exceptions
Coinsurance (COINS) percents of how much the patient and insurance pays after the deductible has been met
most commonly 80/20 where insurance pays 80% & patient pays 20% is an ex of COINS
Comprehensive plan combines benefits of basic & major medical needs; patients total healthcare needs
Consolidated omnibus budget reconciliation act (COBRA) law that allows you to temporarily keep health coverage after employment ends, you pay 100% of the premiums (including the share the previous employer paid) & an administration fee
COBRA applies to these groups former employees/ retirees, their spouses and dependent children
Coordination of benefits (COB) limit the total benefits an insured individual can receive from both group plans to no more than 100% of the allowable expenses; prevents policyholder from making a profit on claims; prevents over insurance
copay set amount paid by the patient based on the type of facility/provider
cost sharing share of costs the patient pays for out of pocket ex) deductible, COINS, copay
deductible amount patient must pay before benefits begin
disability insurance pays the policyholder a sum of money in place of the usual income if the policyholder can’t work in place of accident/ illness
enrollees people covered under managed care plans
episode of care when a single provider is paid a set amount for all services provided by that provider during an “episode”
essential health benefits set of 10 categories that HIM must cover under the ACA. Ex) in/outpatient hospital care, prescription drug coverage, pregnancies & childbirth, mental illness services, etc .Min coverage requirements for all plans in the health insurance marketplace
exclusions illnesses or injuries not covered by the plan
Fee for service (FFS)/ Indemnity payment method in which the provider is paid a fee for performing a service, best for major medical coverage, patient pays upfront, patient or provider can file claims, low premium & high deductible
Flexible spending account (FSA) form of a cafeteria plan benefit, funded by salary reduction that reimburses employees for expenses incurred for certain qualified benefits
Grandfathered plans allows plans to offer the same coverage as before the ACA was effective
group plan health plan offered by an employer/ employee organization that provides coverage to employees and their families
Hardship exemption acquired for certain life situations that prevent an individual from being able to afford health insurance,
ex) home foreclosure incurring substantial debt, etc hardship exemption
Health insurance exchanges/ Health insurance marketplace place where people w/o health insurance can find info about and purchase health insurance
Health reimbursement arrangements (HRA) reimburse employees for qualifying medical expenses funded by funds employers set aside
Health savings account (HSA/MSA tax shelter set up for the purpose of paying medical bills
offers lower premiums, lower taxes, freedom of choice, more cash at retirement, funds can be withdrawn for other purposes but individual will face increased federal taxes & penalties HSA/MSA
owner of the premium/ policy policyholder, subscriber, enrollee, beneficiary (Medicare), sponsor (TRICARE)
Lifetime limits insurance companies cap on what they would spend on the patient for the entire length of the plan after the cap has been reached patients will pay for any exceeding costs for the remainder of the plan
Long term care/ custodial care involves providing an individual with assistance/ supervision w/ ADL’s that the individual can no longer perform on their own
Managed care medical care provided by a corporation under state and federal laws that makes decisions for its enrollees to maintain low costs
Medicaid joint federal-state health program administered by individual states, coverage varies between the states, it covers low income individuals, pregnant woman, children, certain disabled individuals
Medically necessary healthcare services/ supplies needed to prevent diagnose or treat an illness, injury, condition, disease, or symptoms that meet accepted standards of medicine
Medicare federal insurance program for individuals 65+ & individuals under 65 with certain disabilities
Medigap/ Medicare supplement plans extra health insurance bought form a private company to pay health care costs not covered by original Medicare
Metal plans/ metal levels levels of coverage grouped by how much the plan will pay and what services will be covered, each level is named after a type of metal
bronze (basic), silver, gold, platinum metals in the metal plan
Nonparticipating provider (nonPAR) provider and insurance are ‘not under contract/ not participating’; provider does not have to accept the insurance company’s fees in full payments, patients may be billed for balance billing
Out of pocket (OOP) max max policyholder must pay for services for the calendar year before insurance will pay 100%
copays, deductibles, COINS, non-covered service cost are what type of expense OOP expense
Participating provider (PAR) provider and insurance are ‘under contract/ participating’; provider accepts the insurance company’s fees as payments once the patient has met the deductible, provider cannot bill the patient for any balances
Preexisting condition physical or mental illness that existed before the new insurance policy becomes effective
Premium amount paid for insurance coverage
Premium reimbursement arrangement (PRA) it allows their employees to reimburse themselves for their individual health insurance costs with pretax wages resulting in immediate savings on health insurance premiums & the business gets savings on FICA taxes on all reimbursements
best plan option for businesses that don’t offer health benefits to their employees or when a new business is started Premium reimbursement arrangement (PRA)
Preventive services routine healthcare that prevents illness, disease, etc. such as checkups, screenings, counseling
services include cancer screenings, routine vaccinations, flu/ pneumonia shots, blood pressure tests, diabetes test, regular well child visits from birth-21 Preventive services
Resource based relative value scale (RBRVS) formula established by CMS that assigns a value to every procedure to calculate Medicare’s fee allowance
formula in which, the cost of providing services are divided into physician work, practice expense, professional liability insurance RBRVS
Social security disability insurance (SSDI) insurance program for individuals who become unable to work, administered through the SSA & funded by FICA tax withheld from workers’ pay and by matching employers contributions
Standardized Benefits and Coverage rule (SBC) intentions to help consumers better understand new/ current insurance policies; replacing certificate of coverage
provides specific elements as followed: what the policy does and does not cover, cost of premium & cost sharing requirements, info regarding any exceptions, reductions, or limitations under the policy SBC
TRICARE US military comprehensive healthcare program for active duty, eligible family members, retirees, family member younger than 65, survivors of all uniformed services
Usual, customary, reasonable (UCR) rates apart of the providers charge that insurance carrier allows as a covered expense , 3rd party insurers have different rates
Value based care better healthcare at a lower cost, payments are based on the “value” of the care they deliver
Workers comp insurance pays workers who are injured/ disabled on the job or have job related illnesses
Catastrophic plans available to people under 30 or have a hardship extension
alternative types of health plans EPO, HMO, POS, PPO
(EPO) exclusive provider organization members can use providers within the network but cannot go outside of that network
(HMO) health maintenance organization offers a local network for the member to choose from and will not cover out of network providers in exception to emergency
(POS) point of service members must have an in network PCP but may go outside the network for services
(PPO) preferred provider organization most popular, allows you to visit any in network provider w/o a referral from PCP, members may go out of network for services but will be a greater cost
difference between HMO & PPO the size of the networks, ability to see specialists, plan costs, coverage for out of networks
Created by: pct120