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HS insurance
| Term | Definition |
|---|---|
| Insurance claim | how you tell your insurer that something happened and ask them to help cover the cost, formal request to insurance company |
| Copay | A fixed amount a patient pays out-of-pocket for a healthcare service at the time of the visit, while the insurance covers the rest (the ticket to see the doctor) |
| co- insurance | the percentage of the cost of a covered healthcare service that you pay after you’ve met your deductible. The insurance company pays the rest (normally 80/20 and you pay smaller amount, you and insurance share cost of bill) |
| CPT codes | standardized medical codes used by doctors and hospitals to describe the procedures and services they perform(“price tags” for medical services. They tell insurance what the doctor did) |
| Insurance deductible | amount of money you must pay out-of-pocket for covered healthcare services before your insurance company starts to pay. (You pay first — insurance pays after, it is the starting amount to must cover before benefits) |
| Diagnostic Related groups | system used by hospitals and insurance companies to classify patients into groups based on their diagnosis, treatment, and other factors. (“price packages” for hospital stays. The hospital gets one set payment for treating a specific type of illness) |
| EPO | where you must use doctors, hospitals, and specialists within the plan’s network to have your care covered. (“In-network only.” You have to stick to the approved list of providers) |
| Expenditures | the money spent by an individual, organization, or government to buy goods, services, or pay for other obligations (money going out. It’s basically any spending) |
| Fee for service insurance plan | insurance company pays for each individual medical service you receive. pay for each service individually. The more services you use, the more the insurance pays (and sometimes the more you pay too |
| Financing | providing or obtaining money to pay for a purchase. In healthcare or business, it often refers to how services, equipment, or operations are funded. (how you get the money to pay for something. It’s like arranging the funds before spending) |
| Healthcare or Medical Fraud | Healthcare or medical fraud is when someone lies or gives false information to get money or benefits from a health insurance program or healthcare provide (It’s like cheating the healthcare system |
| HMO | requires you to use doctors and hospitals within its network and usually needs a referral from your primary care doctor to see a specialist |
| ICD-10 Codes | a standardized system of codes used to classify and describe diseases (It’s like a universal language for doctors and insurance companies to describe what’s wrong with a patient so everyone understands exactly the same thing) |
| Managed Care | a healthcare system designed to control costs managing how patients receive care. (It’s like having a healthcare “plan manager”—you get care through certain doctors and follow certain rules so your care is coordinated and costs are controlled) |
| Medicaid | ree or low-cost healthcare to people with low income, including families, children, pregnant women, elderly adults, and people with disabilities (It’s like safety-net healthcare—helping people who can’t afford medical costs get the care they need) |
| Medicare | a federal health insurance program in the U.S. primarily for people aged 65 and older, and also for certain younger people with disabilities or specific conditions (It’s like health insurance for older adults (and some people with disabilities) |
| Negotiated Fees | are discounted rates that healthcare providers agree to accept from insurance companies for covered medical services |
| Point of Service (POS) | a type of health insurance that combines features of HMO and PPO plans, allowing members to choose in-network care for lower costs or go out-of-network for higher cost |
| Pre-existing Condition | A pre-existing condition is a health problem or illness that existed before someone’s health insurance coverage began |
| Preauthorization | Preauthorization is when your insurance company must approve a medical service or prescription before you receive it to confirm it’s covered |
| PPO(Preferred Provider Organization) | a health insurance plan that lets you see any doctor but offers lower costs when you use doctors and hospitals within its network |
| Premium | the amount of money you pay, usually monthly, to have health insurance coverage |
| Prepaid Plans | health insurance plans where you pay a fixed amount in advance for access to a set range of medical services |
| PCPs | a doctor who serves as your main healthcare provider, managing your overall care and referring you to specialists when needed |
| Primary Care Physician | a doctor who provides general healthcare, treats common illnesses, and coordinates specialist care when needed |
| Profit | the money a company has left after subtracting all its costs and expenses from its total income |
| Reimbursement | the payment a healthcare provider or patient receives from an insurance company for medical services that were provided or paid for |
| Veterans Health Administration | a government-run system that provides healthcare services to eligible U.S. military veterans |
| Out of Pocket Max ( or limit | the most you’ll have to pay for covered healthcare in a year before your insurance pays 100% of the costs |
| Capitation | a payment arrangement where healthcare providers are paid a fixed amount per patient, regardless of how many services the patient uses |
| CMS | a U.S. government agency that administers Medicare, Medicaid, and other health-related programs |
| MARKETPLACE: | an online platform where individuals and families can compare, shop for, and enroll in health insurance plans |
| EOB | a statement from your insurance company that explains what medical services were covered, how much was paid, and what you may ow |
| COBRA: | a law that lets you temporarily keep your employer-sponsored health insurance after leaving a job |
| Part A, Hospital insurance | covers inpatient hospital stays, skilled nursing facilities, hospice care, and some home health care |
| Part B, Medical insurance | doctors visits, outpatient care, preventive services, durable medical equipment |
| Part C. Medicare advantage | Medicare advantage: An alternative to Original Medicare; offered by private companies, usually combines part A and B, may include extra benefits like vision or dental |
| Part D, prescription | Drug coverage: helps pay for prescription medications: offered through private insurance plans |
| Original medicare | Part A and Part B combined, government run and is flexible |
| Who pays for Medicaid | The federal government and state share the cost |
| CHIP | Children's Health insurance program . Main purpose is to provide low cost health coverage to children in families who earn too much for Medicaid but can't afford private insurance |
| What types of healthcare services does CHIP help cover for children? | It covers basic healthcare like doctor visits, vaccines, check ups, prescriptions,and dental and vision |
| What was the main goal of the Affordable Care Act (ACA) when it was passed in 2010? | o expand access to affordable health insurance and improve quality of healthcare |
| What age can young adults remain on their parents’ health insurance plan under the ACA? | age 26 |
| Capitation | Providers are paid a fixed amount per patient, regardless of how many services are used |
| Bundled Payment / Episode-of-Care Payment | A single payment covers all services related to a treatment or condition |
| Pay-for-Performance (P4P) | Providers are rewarded for meeting certain quality and efficiency measures |
| Ambulatory patient services | outpatient care |
| excise tax | A special tax placed on specific goods or services (for the ACA, this included things like indoor tanning services and high-cost insurance plans, often called “Cadillac plans”). |
| DRG´s | efforts imposed by the government and managed care to lower healthcare costs |
| How much does US pay in healthcare ina year | 3.8 trillion dollars |
| most influential single payer system country | united kingdom |
| How is the NHS supported | tax funding |
| who has access to NHS | everyone in the UK |
| Disadvantage to single payer systems | longer wait times |
| NICE | examines evidence for any given treatment or procedure and weighs which are the most cost effective or pateints |
| Achieved universal health care | switzerland |
| what is Swiss coverage | variety of options |
| Crucial innovation for swiss healthcare system | 1994 law |
| 1994 law | mandates everyone buy basic health insurance |
| What does Swiss government mandate | everyone buy basic health insurance |
| Canada is a ... | single payer system |
Created by:
Darcy.study