provides prepaid plans to cover hospitalization costs
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Blue Shield
groups of physicians used to cover physician service fees
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Social Security Act of 1965
The most significant change in government healthcare financing which approved the Medicare and Medicaid programs
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government institution
receives most of its funding from local, federal, or state sources
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voluntary nonprofit institution
receives federal, state, and local tax exemptions in exchange for providing community benefits
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proprietary institution
for-profit institutions usually owned by corporations
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government plans
healthcare plans funded by the government
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TRICARE
an insurance system for active and retired service personnel
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Medicare
healthcare program for older Americans 65 or older; uses prospective payment system
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prospective payment system
pays healthcare provider a fixed amount based on diagnosis or specific procedure, rather than actual cost
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Medicaid
offers insurance to low-income and disabled people
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Medicare Part A
inpatient hospital care not requiring premium
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Medicare Part B
outpatient care services
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Medicare Part C
allows people to buy into private health insurance
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Medicare Part D
gives prescription drug coverage
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Medicare Advantage
another name for Medicare Part C
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1970
the year managed care was started
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health insurance
in place to protect yourself if you get sick or injured
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COBRA
gives people the right to continue a work-based group plan after a job loss, death of spouse, divorce, or eligibility loss for dependent coverage
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26 years old
the age a person can stay on their parents plan for
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premium
the monthly amount paid to a private insurance company for health insurance coverage
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deductible
the money a person must pay yearly before an insurance company provides benefits
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out-of-pocket
the total amount of money payed for care that is not covered by insurance
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copay
a flat fee that many health insurance plans require patients to pay each time they receive health care service.
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co-insurance
the portion of medical costs a patient may still have to pay once deductible has been payed
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out-of-pocket max/limit
the highest out-of-pocket amount that can be paid before insurance pays for everything including copay and co-insuarnce.
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in-network provider
a health care provider that has a contract with a managed care insurance plan
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out-of-network provider
a healthcare provider who is not in a particular managed care health insurance plan
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50+ employees
a work place is required to get employee health insurance benefits if they have this many employees.
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Affordable Care Acts
takes into account age, location, tobacco use, individual or family plan, and plan category to determine premium
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Health Savings Account (HSA)
a monetary account commonly paired with a high-deductible health insurance plan that allows individuals to pay for qualified medical care using pre-tax dollars until they meet their deductibles. Any funds remaining at the end of each year are rolled over and can be saved for future use.
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Flexible Spendings Account (FSA)
a monetary account, offered through an employer, into which money is put through payroll deductions, before it is taxed. Funds can be withdrawn for qualified medical expenses as needed, but the funds must be spent each year.
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Diagnostic Related Groups (DRGs)
a classification system used by Medicare and Medicaid to determine payment for health services based on diagnosis, surgical procedure, age, other information
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Direct payment
the act of paying for health care with one's own money
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gatekeeper
a physician who not only delivers primary care services, but also makes referrals for specialty care.
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healthcare cost containment
measures designed to lower health care costs that aim to create an affordable health care system for all Americans.
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managed care
a type of health insurance plan that establishes predetermined rates for services with health care providers such as doctors and hospitals, and puts providers in the position of managing patients' use of health care.
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Health Maintenance Organization (HMO)
a health insurance plan that provides coverage only if the care is delivered by a member of the plan's hospital, physician, or pharmacy panel.
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point-of-service (POS)
a physician-coordinated health insurance plan that combines characteristics of both HMO and PPO plans
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Preferred Provider Organization (PPO)
a health insurance plan that allows patients to receive care from a non-plan provider, but requires them to pay a higher out-of-pocket price if they do so.
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private insurance
a health insurance system that allows individuals to obtain group health benefits through an organization, such as an employer, a union, or an association
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resource utilization
making better use of health care resources to cut costs
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utilization review
a process in which an insurer reviews decisions by physicians and other providers about how much care to provide.
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How do you calculate cost after Insurance
Deductible > Copay > co-insurance >
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US healthcare spendings projected growth between 2008-2018
6.2 percent
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percent of spendings going to healthcare
20.3 percent
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examples of voluntary non profit institutions
clinics, services for those who cannot afford it
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examples of proprietary institutions
usually a "chain", multiple facilities in multiple states
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examples of government institutions
military treatment facilities, veteran affairs hospitals (VA), public or government funded hospitals, state mental hospitals, state rehabilitation facilities
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how is healthcare paid for in the us?
government plans, private insurance, direct payment
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how do most americans obtain health insurance?
through their employer
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what are HMO, PPO, and POS plans?
manage care plans
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how are managed care plans different from conventional plans?
managed health care plans are dependent on a network of health care providers, doctors, and facilities that establish a contract with an insurance provider.
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How do DRGS affect the amount paid to providers for health care services?
generally, services will cost less with DRGs, which lower the amount of money that healthcare providers will receive.
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why should healthcare workers practice resource utilization?
To conserve resources, time, and energy to be able to treat more patients more efficiently.
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