Health Insurance CH.2

Medical Care

Identification of diseases and provision of care and treatment to sick or injured individuals.

Health Care

Expands on medical care to include preventive services to avoid health and injury problems.

Express Contract

Provisions that are explicitly stated in the health insurance contract.

Implied Contract

Results from actions taken by the health care facility or provider.

Health Insurance

A contract between a policyholder and a third-party payer to reimburse for medically necessary treatment or preventive care.

Premium

The amount paid for a health insurance policy.

Schedule of Benefits / Covered Services

Outlines services covered by a health insurance plan.

Prepaid Health Plan

Establishes a capitation contract between a managed health care plan and network providers.

Policyholder

Signs a contract with a health insurance company and owns the health insurance policy.

Enrollee or Subscriber

Joins a managed health care plan.

Third-Party Payer

A health insurance company that provides coverage (e.g., Blueshield).

Deductible

The amount the patient is responsible for before insurance payment begins.

Copayment (Copay)

A specified dollar amount the policyholder pays for each medical service received.

Omnibus Budget Reconciliation Act of 1981 (OBRA)

Expanded Medicare and Medical programs and requires retention of insurance claims for five years.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

Allows employees to continue healthcare coverage after termination by paying premiums.

Patient Protection and Affordable Care Act (PPACA)

Focused on private health insurance reform for better coverage and extending Medicare Trust fund life.

Managed Care

A health care delivery system organized to manage cost, quality, and utilization.

Managed Care Organization (MCO)

Responsible for the health of a group of enrollees, can be a health plan, system, hospital, or physician group.