Health Insurance Plan & MCO Overview

These flashcards cover key terms and definitions related to health insurance plans and managed care organizations, essential for understanding the subject matter for the exam.

Group Health Insurance

Health coverage provided by employers or organizations, often with lower premiums and broader benefits due to pooled risk.

HIPAA

A federal law from 1996 that prevents denial of coverage for pre-existing conditions (under certain rules) and protects patient health information privacy.

Fully Insured Employer Group

An employer pays a fixed premium to an insurer, who then manages claims and assumes financial risk for employee medical costs.

Self-Funded ERISA

An employer directly pays employee medical claims, assuming financial risk. Often uses a TPA and stop-loss insurance.

Managed Care Organization (MCO)

Systems (like HMOs, PPOs) that control healthcare costs and quality through provider networks, pre-authorizations, and preventive care.

Health Maintenance Organization (HMO)

A managed care plan where members choose a PCP (gatekeeper) who coordinates all care. Usually covers only in-network providers (except emergencies).

Preventative Care

Healthcare services aimed at preventing illness, such as immunizations, annual physicals, and screenings.

Preadmission Certification

Insurance approval required before hospital admission or certain procedures, confirming medical necessity and coverage.

Capitation

A payment model where providers receive a fixed amount per patient per month, regardless of services used, incentivizing efficient care.

Deductible

The amount an insured person pays out-of-pocket for covered services before insurance starts paying.

Coinsurance

A percentage of healthcare costs you pay after meeting your deductible. For example, if your coinsurance is 20\% and the covered service costs 100\, you pay 20\.

Non-Participating Provider (nonPAR)

A healthcare provider without a contract with your insurance plan. You'll likely pay more out-of-pocket and may be balance billed.

Preferred Provider Organization (PPO)

A flexible health plan allowing members to choose in-network or out-of-network providers without referrals, though out-of-network costs are higher.

Triple Option Plans

Health plans offering a choice of three benefit options, typically combining elements of HMO, PPO, and indemnity plans.

Medicaid

A joint federal and state program providing health coverage to low-income individuals, children, pregnant women, the elderly, and people with disabilities.

Accountable Care Organizations (ACO)

Groups of providers coordinating care for Medicare patients to improve quality and reduce costs, sharing savings if goals are met.

Consumer Driven Health Plans (CDHP)

High-deductible health plans combined with tax-advantaged savings accounts (like HSAs/HRAs) to give consumers more control over spending.

Indemnity Insurance Plan

A traditional, flexible fee-for-service plan allowing choice of any provider. The plan pays a percentage after a deductible; the patient pays the rest.

Lifetime limits

Historically, caps on total insurance payouts. The ACA broadly prohibited these limits on essential health benefits for most plans.

Children's Health Insurance Program (CHIP)

A federal and state program offering low-cost health coverage for children in families who earn too much for Medicaid but can't afford private insurance.