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PHS - Insurance
| Question | Answer |
|---|---|
| State Health Services | - Texas department of health - State university medical centers - State mental health hospitals - Texas school for the blind -Texas school for the deaf |
| Federal Health Services | U.S. Public Health Department Veterans Administration hospitals (CDC), (NIH), (FDA), (OSHA, (USDHHS) |
| Non-Profit Agencies | American Cancer Society American Heart Association American Diabetes Assoc. March of Dimes Red Cross |
| Deductible | The amount a patient pays toward certain covered medical expenses before insurance begins sharing those costs. |
| Co-Pay | A fixed dollar amount a patient pays for certain covered healthcare services. Ex. $30 for an office visit. |
| Coinsurance | The percentage of covered medical expenses a patient pays, usually after meeting their deductible. |
| Premium | the amount of money that you and/or your employer pays the insurance company every month |
| Out-of-pocket Maximums | The most a patient pays in covered cost sharing during a plan year. Once reached, insurance pays 100% of covered in-network expenses. |
| Exclusions | things that aren’t covered have to be paid in full by patient |
| HMO – Health Maintenance Insurance | A health insurance plan that typically requires patients to use network providers and obtain referrals for certain specialist visits. |
| PPO – Preferred Provider Organization | A health insurance plan that generally offers more provider flexibility, including some out-of-network coverage, usually at a higher cost. |
| Medicare | Federally funded, for individuals age of 65 and older or who meet other social criteria |
| Medicaid | Government health insurance funded jointly by federal and state governments for eligible individuals based on income and other requirements. |
| Medicare type A | Generally covers inpatient hospital care, skilled nursing facility care under certain conditions, hospice, and some home healthcare. |
| Medicare type B | Generally covers outpatient medical services, including physician visits, preventive services, and certain medical equipment. |
| Worker’s Compensation | Provides compensation for employees who are injured on the job and helps with lost wages while out on leave - Paid for by state and employer |
| TRICARE | Covers military families |
| Other insurances you can have | Cancer, Vision, Disability (Aflac), Dental and Life |
| Marketplace | service to shop for affordable plan not associated with your job |
| dental office | provides oral care for teeth |
| industrial | provides care for employees |
| optical office | provides care for vision |
| mental health | treats mental disorders |
| hospice | provides end of life care |
| genetic counseling | helps families with genetic abdnormalities |
| home health | provides care in the patient's home |
| rehabilitation | provides care for those with physical or mental needs (physical, speech, occupational, hearing) |
| laboratory | performs diagnostics tests on fluids |
| school health | provides emergency care and screenings for students |
| private hospital funding | grants, insurance, and private pay |
| government hospital funding | taxes and charitable donations |
| long-term care facilities | ongoing care - independent living - assisted living |
| who supports volunteer or non-profit agencies | donations, membership fees, fundraiser, or grants |
| Independent Living | Housing for individuals who can care for themselves but want fewer household responsibilities and opportunities to socialize. |
| Assisted Living | Residential care for individuals who need help with daily activities such as bathing, dressing, or preparing meals. |
| Skilled Nursing Facility | Provides ongoing nursing care and medical services for patients who need more assistance than assisted living provides. |
| Prior Authorization | Approval required from an insurance company before certain medical services or procedures will be covered. |
| Referral | When a healthcare provider directs a patient to another healthcare professional, often a specialist. |
| In-Network Provider | A healthcare provider who has a contract with an insurance company to provide services at negotiated rates. |
| Out-of-Network Provider | A healthcare provider who does not have a contract with the patient's insurance plan. Patients may pay more for services. |
| Supplemental Insurance | Additional insurance that helps pay expenses associated with specific conditions or situations, such as cancer or disability. |
| Health Insurance Marketplace | A service where individuals and families can compare and purchase health insurance plans. |
| Centers for Medicare & Medicaid Services (CMS) | Federal agency that oversees Medicare, Medicaid, and CHIP. |
| CHIP | Children's Health Insurance Program, provides coverage to eligible children whose families earn too much for Medicaid but need affordable insurance. |
| Workers' Compensation | Provides benefits for employees who experience work-related injuries or illnesses, including medical care and possible lost wages. |
| What counts toward the out-of-pocket maximum? | Deductibles and coinsurance for covered in-network services generally count. Monthly premiums do not. |
| What happens after meeting the deductible? | The patient may still pay coinsurance or copayments until reaching the out-of-pocket maximum. |
| What happens when you reach your out-of-pocket maximum? | Your insurance pays 100% of covered, in-network medical expenses for the rest of the plan year. You must still pay your monthly premiums. |
| How do for-profit organizations and non-profit organizations use their surplus revenue (extra money) differently? | For-profit: A portion of the surplus can be paid out directly to shareholders or owners. Non-profit: A portion of the surplus can be paid out directly to shareholders or owners |
Created by:
adittrich