Types of Health Insurance Plans and Key Terminology

Flashcards outlining key concepts and terminologies related to health insurance plans for medical assistants.

Private Insurance

Health insurance provided by companies like Blue Cross Blue Shield, Aetna, Cigna, and UnitedHealthcare, available as employer-sponsored or individual plans.

HMO

Health Maintenance Organization; a type of insurance plan that requires members to use a network of doctors and requires referrals for specialists.

PPO

Preferred Provider Organization; a type of insurance plan that allows patients to see any doctor or specialist without a referral but offers lower costs for using network providers.

EPO

Exclusive Provider Organization; a type of insurance plan that only covers care provided by doctors who work for the EPO except in emergencies.

POS

Point of Service; a type of insurance plan that combines features of HMO and PPO plans.

Medicare

Federal insurance program for seniors (65+) and some disabled individuals.

Medicaid

State and federal program that provides health coverage for low-income individuals and families.

TRICARE

Health care program for military personnel and their families.

CHIP

Children's Health Insurance Program; covers children in low-income families who do not qualify for Medicaid.

Workers' Compensation

Insurance that covers medical expenses for job-related injuries.

Premium

The monthly payment for insurance coverage.

Deductible

The amount a patient must pay out-of-pocket before insurance begins covering costs.

Copayment (Copay)

A fixed amount that a patient pays at each visit.

Coinsurance

The percentage of costs the patient shares after the deductible has been met.

Out-of-Pocket Maximum

The most a patient will pay in a year before insurance covers 100% of expenses.

Prior Authorization

Insurance approval required before certain procedures, medications, or specialist visits.

Verifying Insurance and Eligibility

The process of confirming active coverage, checking for referrals or prior authorizations, and determining patient responsibility before an appointment.