Health Financing and Insurance Models

Vocabulary flashcards covering health financing concepts, cost-sharing mechanisms, provider payment methods, provider networks, and health insurance plan types.

Health Financing System

A system that pools the financial consequences of ill health through risk aversion, risk pooling, and saving money.

Risk Pooling

The practice of combining the financial risks and consequences of ill health across a group of individuals.

Obligations

The terms, rules, and requirements stipulated within an insurance contract that an insured person must follow.

Premium

The upfront payment required by an insurance company in order to become a member and obtain medical claim coverage.

Deductible

The out-of-pocket amount an insured individual must pay after becoming a member before the insurance company covers medical claims.

Co-payment

A fixed, typically small fee paid by an insured person for each medical claim, commonly applied to outpatients to discourage moral hazard.

Coinsurance

A fixed percentage of medical costs that the insured member is required to pay.

Exclusion

Specific medical services not covered under the insurance contract, such as aesthetic procedures, liposuction, and dental services.

Coverage Limits

The maximum amount of money an insurance company will cover to protect itself, leaving any remaining expenses to be paid out of pocket by the insured.

Out of Pocket Maximum

The maximum total amount of money an insured individual will pay out of pocket, which includes both the deductible and coinsurance.

Capitation

A provider payment mechanism ('swelduhan') delivering a fixed income that does not vary with patient volume, helping to reduce moral hazard.

Fee for Service

A payment model where healthcare providers are reimbursed per patient, service, or procedure performed, allowing higher case counts to generate greater income.

Moral Hazard (Provider-side)

A risk under fee-for-service payment where a physician may perform unnecessary procedures or require repeated visits to inflate revenue.

Moral Hazard (Patient-side)

A behavioral shift in an insured person resulting in overutilization of medical care, such as seeking excessive check-ups when no co-payment is imposed.

In-Network Provider

Doctors and medical facilities that are officially recognized and contracted by a health insurance organization.

Out-of-Network Provider

Healthcare providers not recognized by the insurance organization, resulting in reduced benefits and higher out-of-pocket costs for the patient.

HMO (Health Maintenance Organization)

A managed care model with traditional characteristics including all in-network care, capitation payments to PCPs, and generally no deductibles or coinsurance.

PCP (Primary Care Physician or Provider)

A regular physician assigned to a patient based on geographic location who provides general care and specialist referrals within an HMO network.

PCP Assignment in the Philippines

The conventional practice in Philippine HMOs where insured individuals generally do not have an assigned Primary Care Physician.

Yakap

A healthcare program in the Philippines that provides insured members with an assigned Primary Care Physician (PCP).

Internist

A physician specializing in internal medicine recognized as an eligible Primary Care Physician (PCP).

Family Doctor

A general medical practitioner eligible to serve as a member's designated Primary Care Physician (PCP).

Pediatrician

A medical specialist focused on the care of children who qualifies as an eligible Primary Care Physician (PCP).

GP (General Practitioner)

A non-specialized physician providing comprehensive primary medical care who can serve as an assigned Primary Care Physician (PCP).

PPO (Preferred Provider Organization)

A health plan that allows patients to seek care out of network, providing increased benefits for in-network care and reduced benefits for out-of-network care.

EPO (Exclusive Provider Organization)

A health plan similar to a PPO, but strictly restricted to in-network services with no coverage for out-of-network providers.

POS (Point of Service)

A hybrid plan combining HMO and PPO features, which requires an assigned PCP while still offering both in-network and out-of-network coverage.

Indemnity Plan

A fee-for-service plan often utilized by employees of large corporations where reimbursement is based directly on the specific services rendered by healthcare practitioners.

High Risk Insurance Pools

Subsidized insurance pools with high premiums created for individuals with pre-existing medical conditions whom standard insurers typically avoid enrolling.

Catastrophic Health Insurance

An insurance option available to individuals aged 30 and below designed to guard against unexpected medical costs and accidents while excluding most routine services.