Insurance CMAA - Midterm Test

youre joekin.

What is health insurance?

A contract between a patient and health insurance carrier

What is the purpose of a health insurance contract?

Determines the payments that helps you

What is health insurance carrier?

A company that provides health insurnace plans

What is insurance benefits?

Necessary services that the insurance carrier will cover or reimburse

Give 2 examples of insurance benefits

• vision/dental care

• labs and xrays

Who selects the coverage plan?

Patients

What does the health insurance carrier agree to do when it issues a policy?

Agrees to provide benefits for covered services

Why should patients examine their policies carefully?

carriers will cover certain things, not all

What is montly premium?

a fee patients pay to be in an insurance plan

when is the premium paid?

Monthly

What are family members added to a policy called?

beneficiary (you must pay higher deductables)

What is a deductable?

fixed amount of money patient pays before appointment

who sets the ammount for the deducable and when?

The carrier, every year

What is coinsurance?

a fixed %

What is copayment?

fixed amount (MOST COMMON BEING 25)

What is an exclusion?

provision that eliminated your coverage completly — doesnt help you pay for it

examples of exclusion

• cosmetic surgery

• transferring lungs

what happened in 1850s that influenced the development of health insurance?

covered common diseases at the time

what did blue cross offer in 1929?

hospital service for 6$ a year

when did mannaged care approach become popular?

1990s

what act was passed in 2010?

passed a patient protection and affordable act

How is group insurance more commonly available?

by employes

what is an individual healthcare plan?

purchases a policyand agrees to pay ENTIRE premium

How has the 2010 act affect individual?

More affordable and more options

where does private insurance funding come from?

enrolles

Where does public insurance funding come from?

goverment

Other names for fee-for-service plan

indemnity plan, or traditional service

What is fee-for-service plan?

patient pays from their pocket, and patient gets reimbursed by the carrier for their expensive (gets paid back after paying for EVERYTHING)

2 concepts of managed care?

practice good health, practice preventative medicine

what is managed care?

system of healthcare workers who are contracted to provide services at reduced rates

Medicare

funded by federal government pays this, for 65+

Medicaid

funded by state government, people with low income

Workers compensation

funded by state government and employers, people injured on their jobs

how is managed care cheaper?

contact a network of physicians and hospitals

what is preventive care?

services with the goal to prevent future injuries/illneses

• to avoid expensive problems

define HMO

Health Maintenance organization

How is HMO paid?

monthly premium, paid by petient, empoloyer, or both

Staff (HMO)

hires groups of physician and pays them salary wages

Group (HMO)

contracts with multispeciality group of physicians that usually practice in the same facility

IPA (HMO)

independent practice association

• physicians with independent policies

EPO (HMO)

Exclusive provider orgainization

• combines HMO and PPO features

• physician reimbursed based on fee-for-service

PPO meaning?

preferred provider organization

PPO in out of network, what occurs?

out of pocket expenses are higher

how does PPO reimburse providers?

a fee for service

define POS

P0int 0f service (n0 deductable)

what must POS enrollees select before applying?

a primary care physician