Question 1

administrative services only (ASO)

Accepted Answer

Contract under which a third-party administrator or an insurer agrees to provide administrative services to an employer in exchange for a fixed fee per employee.

Question 2

BlueCard

Accepted Answer

A BlueCross BlueShield program that provides benefits for plan subscribers who are away from their local areas.

Question 3

BlueCross BlueShield Association (BCBS)

Accepted Answer

A national healthcare licensing association of more than forty payers.

Question 4

concierge medicine

Accepted Answer

A primary care arrangement with a patient under which the provider agrees to accept a retainer in exchange for enhanced care and access to the patient.

Question 5

Consolidated Omnibus Budget Reconciliation Act (COBRA)

Accepted Answer

Federal law requiring employers with more than twenty employees to allow employees who have been terminated for reasons other than gross misconduct to pay for coverage under the employer’s group health plan for eighteen months after termination.

Question 6

credentialing

Accepted Answer

Periodic verification that a provider or facility meets the professional standards of a certifying organization; physician credentialing involves screening and evaluating qualifications and other credentials, including licensure, required education, relevant training and experience, and current competence.

Question 7

direct primary care (DPC)

Accepted Answer

An arrangement between a provider and a patient that removes an insurance plan; it is usually paired with either a high-deductible health plan or an HRA/FSA.

Question 8

discounted fee-for-service

Accepted Answer

A negotiated payment schedule for healthcare services based on a reduced percentage of a provider’s usual charges.

Question 9

elective surgery

Accepted Answer

Nonemergency surgical procedure that can be scheduled in advance.

Question 10

Employee Retirement Income Security Act (ERISA) of 1974

Accepted Answer

A federal law that provides incentives and protection against litigation for companies that set up employee health and pension plans.

Question 11

episode-of-care (EOC) option

Accepted Answer

A flat payment by a health plan to a provider for a defined set of services, such as care provided for a normal pregnancy, or for services for a certain period of time, such as a hospital stay.

Question 12

essential health benefits (EHB)

Accepted Answer

Required benefits that must be offered by metal plans as well as some other insurance plans.

Question 13

family deductible

Accepted Answer

Fixed, periodic amount that must be met by the combination of payments for covered services to each individual of an insured/dependent group before benefits from a payer begin.

Question 14

Federal Employees Health Benefits (FEHB) program

Accepted Answer

The health insurance program that covers employees and retirees and their families of the federal government.

Question 15

Flexible Blue

Accepted Answer

The BlueCross BlueShield consumer-driven health plan.

Question 16

flexible savings (spending) account (FSA)

Accepted Answer

Type of consumer-driven health funding plan option that has employer and employee contributions; funds left over revert to the employer.

Question 17

formulary

Accepted Answer

A list of a health plan’s selected drugs and their proper dosages; often a plan pays only for the drugs it lists.

Question 18

group health plan (GHP)

Accepted Answer

Under HIPAA, a plan (including a self-insured plan) of an employer or employee organization to provide healthcare to the employees, former employees, or their families. Plans that are self-administered and have fewer than fifty participants are not group health plans.

Question 19

health insurance exchange (HIX)

Accepted Answer

Government-regulated marketplace offering insurance plans to individuals.

Question 20

health reimbursement account (HRA)

Accepted Answer

Type of consumer-driven health plan funding option under which an employer sets aside an annual amount an employee can use to pay for certain types of healthcare costs.

Question 21

health savings account (HSA)

Accepted Answer

Type of consumer-driven health plan funding option under which employers, employees, both employers and employees, or individuals set aside funds that can be used to pay for certain types of healthcare costs.

Question 22

high-deductible health plan (HDHP)

Accepted Answer

Type of health plan combining high-deductible insurance, usually a PPO with a relatively low premium, and a funding option to pay for patients’ out-of-pocket expenses up to the deductible.

Question 23

home plan

Accepted Answer

BlueCross BlueShield plan in the community where the subscriber has contracted for coverage.

Question 24

host plan

Accepted Answer

Participating provider’s local BlueCross BlueShield plan.

Question 25

independent (or individual) practice association (IPA)

Accepted Answer

Type of health maintenance organization in which physicians are self-employed and provide services to both HMO members and nonmembers.

Question 26

individual deductible

Accepted Answer

Fixed amount that must be met periodically by each individual of an insured/dependent group before benefits from a payer begin.

Question 27

individual health plan (IHP)

Accepted Answer

Medical insurance plan purchased by an individual, rather than through a group affiliation.

Question 28

late enrollee

Accepted Answer

Category of enrollment in a commercial health plan that may have different eligibility requirements.

Question 29

medical home model

Accepted Answer

Care plans that emphasize primary care with coordinated care involving communications among the patient’s physicians.

Question 30

metal plans

Accepted Answer

New health plans created by the ACA named after different types of metals according to the services they cover.

Question 31

monthly enrollment list

Accepted Answer

Document of eligible members of a capitated plan registered with a particular PCP for a monthly period.

Question 32

narrow network

Accepted Answer

Payer network of physicians and hospitals with limited choices for patients.

Question 33

open enrollment period

Accepted Answer

Span of time during which a policyholder selects from an employer’s offered benefits; often used to describe the fourth quarter of the year for employees in employer-sponsored health plans or the designated period for enrollment in a Medicare or Medigap plan.

Question 34

parity

Accepted Answer

Equal in value; refers to comparable coverage for medical/surgical benefits with other benefits such as mental health.

Question 35

pay-for-performance (P4P)

Accepted Answer

Health plan financial incentives program to encourage providers to follow recommended care management protocols.

Question 36

plan summary grid

Accepted Answer

Quick-reference table for frequently billed health plans.

Question 37

precertification

Accepted Answer

Generally, preauthorization for hospital admission or outpatient procedure; see preauthorization.

Question 38

repricer

Accepted Answer

Vendor that sets up fee schedules and discounts, and processes out-of-network claims for payers.

Question 39

rider

Accepted Answer

Document that modifies an insurance contract.

Question 40

Section 125 cafeteria plan

Accepted Answer

Employers’ health plans that are structured under income tax laws to permit funding of premiums with pretax payroll deductions.

Question 41

silent PPO

Accepted Answer

Managed care organization that purchases a list of a PPO’s participating providers and pays those providers’ claims for its enrollees according to the contract’s fee schedule even though the providers do not have contracts with the silent PPO. A provider can avoid having to work with a silent PPO by making sure his or her contract includes language prohibiting the PPO from selling his or her name to another party.

Question 42

stop-loss provision

Accepted Answer

Protection against the risk of large losses or severely adverse claims experience; may be included in a participating provider’s contract with a plan or bought by a self-funded plan.

Question 43

subcapitation

Accepted Answer

Arrangement under which a capitated provider prepays an ancillary provider for specified medical services for plan members.

Question 44

Summary Plan Description (SPD)

Accepted Answer

Legally required document for self-funded plans that states beneficiaries’ benefits and legal rights.

Question 45

third-party claims administrator (TPA)

Accepted Answer

Company that provides administrative services for health plans but is not a contractual party.

Question 46

tiered network

Accepted Answer

Plan feature that pays more to providers that the plan rates as providing the highest-quality, most cost-effective medical services.

Question 47

utilization review

Accepted Answer

Payer’s process to determine the appropriateness of hospital-based healthcare services delivered to a member of a plan.

Question 48

utilization review organization (URO)

Accepted Answer

Organization hired by a payer to evaluate the medical necessity of procedures before they are provided to a member of a plan.

Question 49

waiting period

Accepted Answer

The amount of time that must pass before an employee or dependent may enroll in a health plan.

MED112 CODE/BILL

MED112 KEY TERMS CH 08

Term	Definition
MED112 CH 8 KEY TERMS
administrative services only (ASO)	Contract under which a third-party administrator or an insurer agrees to provide administrative services to an employer in exchange for a fixed fee per employee.
BlueCard	A BlueCross BlueShield program that provides benefits for plan subscribers who are away from their local areas.
BlueCross BlueShield Association (BCBS)	A national healthcare licensing association of more than forty payers.
concierge medicine	A primary care arrangement with a patient under which the provider agrees to accept a retainer in exchange for enhanced care and access to the patient.
Consolidated Omnibus Budget Reconciliation Act (COBRA)	Federal law requiring employers with more than twenty employees to allow employees who have been terminated for reasons other than gross misconduct to pay for coverage under the employer’s group health plan for eighteen months after termination.
credentialing	Periodic verification that a provider or facility meets the professional standards of a certifying organization; physician credentialing involves screening and evaluating qualifications and other credentials, including licensure, required education, relevant training and experience, and current competence.
direct primary care (DPC)	An arrangement between a provider and a patient that removes an insurance plan; it is usually paired with either a high-deductible health plan or an HRA/FSA.
discounted fee-for-service	A negotiated payment schedule for healthcare services based on a reduced percentage of a provider’s usual charges.
elective surgery	Nonemergency surgical procedure that can be scheduled in advance.
Employee Retirement Income Security Act (ERISA) of 1974	A federal law that provides incentives and protection against litigation for companies that set up employee health and pension plans.
episode-of-care (EOC) option	A flat payment by a health plan to a provider for a defined set of services, such as care provided for a normal pregnancy, or for services for a certain period of time, such as a hospital stay.
essential health benefits (EHB)	Required benefits that must be offered by metal plans as well as some other insurance plans.
family deductible	Fixed, periodic amount that must be met by the combination of payments for covered services to each individual of an insured/dependent group before benefits from a payer begin.
Federal Employees Health Benefits (FEHB) program	The health insurance program that covers employees and retirees and their families of the federal government.
Flexible Blue	The BlueCross BlueShield consumer-driven health plan.
flexible savings (spending) account (FSA)	Type of consumer-driven health funding plan option that has employer and employee contributions; funds left over revert to the employer.
formulary	A list of a health plan’s selected drugs and their proper dosages; often a plan pays only for the drugs it lists.
group health plan (GHP)	Under HIPAA, a plan (including a self-insured plan) of an employer or employee organization to provide healthcare to the employees, former employees, or their families. Plans that are self-administered and have fewer than fifty participants are not group health plans.
health insurance exchange (HIX)	Government-regulated marketplace offering insurance plans to individuals.
health reimbursement account (HRA)	Type of consumer-driven health plan funding option under which an employer sets aside an annual amount an employee can use to pay for certain types of healthcare costs.
health savings account (HSA)	Type of consumer-driven health plan funding option under which employers, employees, both employers and employees, or individuals set aside funds that can be used to pay for certain types of healthcare costs.
high-deductible health plan (HDHP)	Type of health plan combining high-deductible insurance, usually a PPO with a relatively low premium, and a funding option to pay for patients’ out-of-pocket expenses up to the deductible.
home plan	BlueCross BlueShield plan in the community where the subscriber has contracted for coverage.
host plan	Participating provider’s local BlueCross BlueShield plan.
independent (or individual) practice association (IPA)	Type of health maintenance organization in which physicians are self-employed and provide services to both HMO members and nonmembers.
individual deductible	Fixed amount that must be met periodically by each individual of an insured/dependent group before benefits from a payer begin.
individual health plan (IHP)	Medical insurance plan purchased by an individual, rather than through a group affiliation.
late enrollee	Category of enrollment in a commercial health plan that may have different eligibility requirements.
medical home model	Care plans that emphasize primary care with coordinated care involving communications among the patient’s physicians.
metal plans	New health plans created by the ACA named after different types of metals according to the services they cover.
monthly enrollment list	Document of eligible members of a capitated plan registered with a particular PCP for a monthly period.
narrow network	Payer network of physicians and hospitals with limited choices for patients.
open enrollment period	Span of time during which a policyholder selects from an employer’s offered benefits; often used to describe the fourth quarter of the year for employees in employer-sponsored health plans or the designated period for enrollment in a Medicare or Medigap plan.
parity	Equal in value; refers to comparable coverage for medical/surgical benefits with other benefits such as mental health.
pay-for-performance (P4P)	Health plan financial incentives program to encourage providers to follow recommended care management protocols.
plan summary grid	Quick-reference table for frequently billed health plans.
precertification	Generally, preauthorization for hospital admission or outpatient procedure; see preauthorization.
repricer	Vendor that sets up fee schedules and discounts, and processes out-of-network claims for payers.
rider	Document that modifies an insurance contract.
Section 125 cafeteria plan	Employers’ health plans that are structured under income tax laws to permit funding of premiums with pretax payroll deductions.
silent PPO	Managed care organization that purchases a list of a PPO’s participating providers and pays those providers’ claims for its enrollees according to the contract’s fee schedule even though the providers do not have contracts with the silent PPO. A provider can avoid having to work with a silent PPO by making sure his or her contract includes language prohibiting the PPO from selling his or her name to another party.
stop-loss provision	Protection against the risk of large losses or severely adverse claims experience; may be included in a participating provider’s contract with a plan or bought by a self-funded plan.
subcapitation	Arrangement under which a capitated provider prepays an ancillary provider for specified medical services for plan members.
Summary Plan Description (SPD)	Legally required document for self-funded plans that states beneficiaries’ benefits and legal rights.
third-party claims administrator (TPA)	Company that provides administrative services for health plans but is not a contractual party.
tiered network	Plan feature that pays more to providers that the plan rates as providing the highest-quality, most cost-effective medical services.
utilization review	Payer’s process to determine the appropriateness of hospital-based healthcare services delivered to a member of a plan.
utilization review organization (URO)	Organization hired by a payer to evaluate the medical necessity of procedures before they are provided to a member of a plan.
waiting period	The amount of time that must pass before an employee or dependent may enroll in a health plan.

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