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MED112 Chapter 8
| Question | Answer |
|---|---|
| Group health plan (GHP) | plan of an employer or employee organization to provide healthcare to employees, former employees, or their families. |
| Rider | document modifying an insurance contract |
| Carve out | part of a standard health plan changed under an employer-sponsored plan |
| Open enrollment period | Time when a policyholder selects from offered benefits |
| Federal Employees Health Benefits (FEHB) program | covers employees and retirees (and their families) of the federal government. |
| Self-funded health plans | ERISA, SPD, TPA, ASO |
| ERISA | Employee Retirement Income Security Act of 1974 |
| SPD | Summary Plan Description |
| TPA | Third-party administrator |
| ASO | Administrative services only |
| COBRA | Consolidated Omnibus Budget Reconciliation Act |
| Consolidated Omnibus Budget Reconciliation Act (COBRA) | law requiring employers with more than twenty employees to allow terminated employees to pay for coverage for eighteen months |
| Preferred Provider Organization (PPO) | Discounted Fee-for-Service |
| Staff Health Maintenance Organization (HMO) | Salary |
| Group HMO | Salary or Contracted Cap Rate |
| Independent Practice Association (IPA) | PCP: Contracted Cap Rate Specialist: Fee-for-Service |
| Point-of-Service (POS) Plan | PCPs: Contracted Cap Rate Referred Providers: Contracted Cap Rate or Discounted Fee-for-Service |
| Indemnity | Fee-for-Service |
| Consumer-Driven Health Plan (Combined High-Deductible Health Plan and Funding Option) | Up to Deductible: Payment by Patient After Deductible: Discounted Fee-for-Service |
| Staff Model | Has everything in one place can only sees only providers staffed by the HMO |
| Group (Network) Model | Doctor who may Par with HMO Doctor paid directly doctor signs a contract with HMO to see their members |
| ndependent (Or individual) Practice Association | Type of HMO Association with doctors from separate practices who agree to see the member of the HMO plan. Negotiate fees with the HMO |
| CDHP's Two Components | high-deductible health plan (HDHP) & Savings Account |
| high-deductible health plan (HDHP) | health plan that combines high-deductible insurance and a funding option to pay for patients’ out-of-pocket expenses up to the deductible. |
| Health reimbursement account (HRA) | requires an employer to set aside an annual amount for healthcare costs. |
| Health savings account (HSA) | Funds are set aside to pay for certain healthcare costs. |
| Flexible spending account (FSA) | employer and employee contributions. |
| Direct Primary Care | a healthcare model where patients pay doctors a flat monthly or annual fee for unlimited access to primary care, bypassing insurance for these services |
| Credentialing | periodic verification that a provider or facility meets professional standards and is qualified to be reimbursed. |
| BlueCross BlueShield Association (BCBS) | is a national organization of independent companies and a federal employee program |
| Pay-for-performance (P4P) | health plan financial incentives program based on provider performance. |
| BlueCard | program that provides benefits for subscribers who are away from their local areas and payments for their treating providers. |
| ost plan | Participating provider’s local BCBS plan. |
| Home plan | BCBS plan in the subscriber’s community |
| Flexible Blue | BCBS consumer-driven health plan. |
| Individual health plan (IHP) | medical insurance plan purchased by an individual |
| Health insurance exchange (H IX) | government-regulated marketplace offering insurance plans to individuals. |
| Metal plans | health plans created by the ACA named after different types of metals (Gold, Silver, Bronze) |
| First part of participation contracts | Introductory section |
| Introductory section | names of parties to the agreement, contract definitions, and the payer. |
| Second part of participation contracts | Contract purpose and covered medical services |
| Contract purpose and covered medical services | Type and purpose of the plan and medical services it covers for enrollees |
| Third part of participation contracts | Physician’s responsibilities as a participating provider |
| Forth part of participation contracts | The plan’s responsibilities toward the participating provider. |
| Fifth part of participation contracts | Compensation and billing guidelines |
| Compensation and billing guidelines | fees, billing rules, filing deadlines, patients’ financial responsibilities, and coordination of benefits |
| Elective surgery | nonemergency surgical procedure |
| Utilization review organization (URO) | organization hired by payer to evaluate medical necessity. |
| Plan summary grid | quick-reference table for health plans: |
| Step 1 in creating summary Grid | Summarizes key items from the contract. |
| Step 2 in creating summary Grid | Provides a shortcut reference for the billing and reimbursement process (including global follow-up times to procedures, preauthorization requirements, etc.) |
| Step 3 in creating summary Grid | Includes information about collecting payments at the time of service and completing claims. |
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