Health Insurance and Payers

Vocabulary flashcards for understanding health insurance and payers, including private and public options, and key insurance terms.

Third Party Payer

An organization other than the patient or healthcare provider involved in financing personal health services.

Health Insurance

A mechanism for protection against financial risk related to healthcare costs.

Premium

Monthly payments for health insurance coverage.

Deductible

The amount you must pay before insurance begins to help pay.

Out-of-pocket maximum

The most you pay in a given year for healthcare expenses.

Indemnity Insurance Plan

Traditional health insurance with high premiums and the least restrictions.

Managed Care Plans

Health insurance plans that may be owned by insurers or providers.

Health Maintenance Organization (HMO)

A managed care plan where patients must receive care from a limited list of providers.

Preferred Provider Organization (PPO)

A managed care plan where patients can receive care from any provider in the network.

Medicaid

Public insurance that provides health coverage based on income eligibility.

Medicare

Federal health insurance for those age 65 or older and some younger people with disabilities.

CHIP

Children’s Health Insurance Program, provides coverage to children.

Private Payers

Health insurance provided by a private insurance company, purchased by the patient or paid for by an employer.

Public Payers

Health insurance provided by state or federal government, paid for by tax dollars.

Risk Pool

A group of individuals whose medical costs are combined to calculate premiums.

Medicare Part A

Hospital insurance covering necessary hospital, nursing home, home health, and hospice care.

Medicare Part B

Medical insurance covering physician services, preventative care, DME, hospital outpatient services and more.

Medicare Part C

Medicare Advantage, allowing HMOs and PPOs to provide coverage in lieu of Part A and B.

Medicare Part D

Optional outpatient prescription coverage provided by private companies.

Veterans Affairs (VA)

Government healthcare coverage to veterans.

TRICARE

Healthcare coverage for active duty and reserve military personnel and their families.

Federal Poverty Guidelines (FPG)

Used to determine eligibility for certain federal programs like Medicaid, states set elegibility as a percentage above the FPG.

Risk

The possibility of substantial financial loss.

Social Security Amendments of 1965

Established Medicare and Medicaid.

Premiums (Private Insurance)

Traditional (indemnity) - High, PPO - Moderate, HMO - Lowest

Deductibles (Private Insurance)

Traditional (indemnity) - Low, PPO - Low or high, HMO - Low

Choice of Provider (Private Insurance)

Traditional (indemnity) - Not limited, PPO - Somewhat limited, HMO - Very limited

Services covered (Private Insurance)

Traditional (indemnity) - All prevention, and a wide range of other services, PPO - All prevention, and a more limited list of other services, HMO - All prevention, and a wide range of other services

Indian Health Service

Another type of public insurance plan.

Eligibility for Public insurance

Based on certain criteria, such as income (Medicaid), age (Medicare), or service (Veteran Affairs/Military).