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| an individual enrolled in a health insurance plan/policy |
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| others on the policy held by the subscriber |
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| monthly fee charged by insurance company |
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| beneficiary receives health services and pays a part and the insurance company pays the other part |
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| list the four types of cost sharing |
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| copayment, coinsurance, deductible, out-of-pocket max |
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| amount paid by the insured, usually a fixed amount |
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| percentage paid by the insured person |
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| amount paid by the insured prior to insurance company paying anything |
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| the max total amount a beneficiary would pay in a year |
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| how often does one pay the premium? |
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| amount you owe for covered healthcare services before your health insurance pays |
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| what payment is lower if your deductible is high? |
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| ______ don't usually count towards your deductible. |
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| ______ never count towards your deductible. |
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| fixed $ amount for healthcare services |
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| These plans were both the simplest and the most popular type of insurance pans for most of the 20th century. In this type of plan, the beneficiary has a fixed amount of cost-sharing regardless of which physician or hospital he or she visits. Beneficiaries are responsible for paying premiums to the insurer and co=insurance (after the deductable has been met) to the provider or facility, while the insurance company reimburses the provider or facility for the majority of the bill. |
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| Managed Care Organization (MCO) |
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Definition
| This plan was implemented in an attempt to constrain costs. Insurance takes more active role in managing the care their beneficiaries receive, rather than focusing solely on premiums and reimbursements. This type of plan stresses the integration of insurance and medical care, especially by exerting more control over providers and patients regarding reimbursement and care utilization. |
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| What is the original Managed Care Plan? (MCO) |
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| Health Management Organization (HMO) |
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| this is the most tightly integrated insurance plan. Beneficiaries can only receive covered care from physicians within the "network" |
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| When a physician is directly employeed by an HMO or signs a contract with the HMO to become "in network", they are called a? |
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| When the HMO emphasizes primary care so much that one must obtain a referral from their PCP (primary care provider) to see a specialists, it's called? |
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| restricting provider choice, gatekeeping, and pre-authorization |
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| 3 "much reviled practices" that HMO's do |
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| Preferred PRovider Organization |
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Definition
| In this plan, providers negotiate contracts with physicians who form the plan's network. Beneficiaries receive discounts from these physicians but still may see physicians out-of-network with higher deductibles, coinsurance, and co-payments to make. |
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| This type of plan is a combo of HMO and PPO but has largely been supplanted by PPO's because nobody wants to see their primary care physician to get a referral to see a specialist |
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| a new type of coverage that can be thought of as tax-free bank accounts that can only be used fir medical expenses. Comes in several formats- health savings accounts (HSA), flexible spending accounts (FSA) and health reimbursement accounts. |
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| the practice of estimating how much medicaal care an individual is likely to need and charging a rate based on that (sicker=more expensive) |
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| In America, the sickest 5% of the population account for ____of total healthcare spending. |
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| When you get insurance through your employer, everyone pays the same amount, regardless of their medical history, this is called? |
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| dividing the total expenses by the number of beneficiaries |
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| In community rating insurance plans, how is the cost of the premium calculated? |
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| Age, geographic location, family composition, tobacco use |
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| After 2014, insurance companies could no longer take past medical history into account for medical underwriting, they can only adjust rates based on? (4 things) |
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| benefit pay out (yours and others) and running the insurance company |
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Definition
| what are your premiums paying for? |
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| the percentage of your insurance premium that actually pays for healthcare |
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| when the employer buys insurance from a private company. The insurer is the payer and takes the risk for future medical costs for the beneficiaries |
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| When the employer takes the responsibility of paying for the employee' medical expenses and the employees still pay a monthly cost but it goes primarily to the employer rather than to an insurance company. this is called? |
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| medicare part... inpatient insurance, covers stays in hospitals and nursing homes, home health visits, and hospice but have a limit on the number of days they will pay for, and they are subject to co-pays and deductibles. |
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