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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
