insurance

insurance

instrument that permits the transfer of risk rare high-cost events

carrier

insurance company that assumes the risk of the unknown costs of health services

risk pool

the group of insureds that share similar risks of incurring health care costs

premium

monthly payment from insureds to the carrier to assume the risk

provider

health professionals or organizations that provide health services

reimbursement

includes 3 parties patient provider insurance carrier

restrospective

payment after service

prospective

payment before service

fee for service

providers receive payment for each service rendered

claim

provider bills for charged services on a form submitted to a carrier

deductible

annual amount paid for services by the insured before the 3pp covers any costs of services

cospayment

moderate fee charged for each episode of care (ex. clinic visits)

coinsurance

percentage of covered services paid by the 3pp and insured

allowable fee

maximum payment the 3pp will reimburse for each service based on the policy contract

usual

typical service charged by a provider

customary

typical average charge in a community of providers

reasonable

typical for the service situation

RBRVS

Medicare physician reimbursement method, based on costs associated with time, effort expenses

managed care

3pp manage both the cost/ outcomes of care, typically combines both financing and provision of services

purpose managed care

reduce cost and ensure quality of care

health maintenance organization

typically organized to provide services in a geographic area

pcp

uses a primary care provider to coordinate all care including referrals

staff model

physicians are employees of the HMO

IPA

independent practice association HMO contracts with individual providers using caption

preferred provider organization PPO

Entity that contracts with employers and carriers to render services through a network of providers for a discounted fee

exclusive provider organization EPO

providers contract exclusively with the MCO. Patients must seek care from network providers or pay all incurred costs Hybrid managed care system. Sponsored by self-insured employers

medicare

amendment to SSA 1965 created title xvii

Medicare part A

inpatient hospital insurance based on income

medicare part B

supplemental medical insurance covers outpatient services

medicare part c

Managed care option called Medicare Advantage acts as substitute for medigap (priv supplemental insurance)

medicare part d

Medicare drug benefit created by the MMA Provides outpatient drug coverage by private plans and Medicare Advantage

Medicaid

Title XIX of SSA, 1965 aka medical assistance

TANF

federal grant funds allocated to states to provide income assistance to the indigent

PACE

Enabling legislation created by the Balanced Budget Act (BBA), 1997 Joint Medicare-Medicaid program offers creating a managed care option for the frail elderly

state children health insurance program (SCHIP)

Title XXI of SSA created by BBA, 1997.state, federal program designed to provide HI to children of families not eligible for Medicaid and unable to afford private coverage

Tricare

DOD program for active duty and retired personnel of all seven military branches

Tricare prime

Tricare managed care options. Services provided by military health facilities. Required when members reside within 50 miles of a military health care facility

tricare remote

Required for members residing farther than 50 miles of a military facility

tricare for life

TLF is secondary coverage for those entitled for Medicare part A

CHAMPVA

Benefits are available to the spouse and children of veterans who: Has a total and permanent disability that is service connected. Died of a service-connected disability. Died on active duty

indian health service IHS

Emanates from the Constitutional relationship
between the US Government and American
Indian tribes established in 1787

workers comp

State insurance funds that cover the cost of,
and lost income associated with work-related
illnesses and injuries

FECA

Federal Employees’ Compensation Act cover federal employees. Established in 1916. Administered by OWCP—Office of Workers Compensation Programs

indemnity

FFS using UCR reimbursement

methods—carrier pays predetermined

percentage, patient pays the remainder.

Permits freedom to select provider.

risk pool

Group of beneficiaries whose health care costs
are combined to determine loss risk and premium rates

underwriting

process of identifying and classifying risk

Blue cross blue shield

Currently a federation of independent, locally operated
plans united through membership in BCBSA

insured

policy holder purchaser of HI

subscriber

AKA certificate holder employee member who receives a cert of insurance coverage

dependents

spouse and family members of subscriber

group number

identifies sets of policies with similar deductible, coinsurance, and copayments

stop loss

Designed to cover catastrophic illnesses and injuries AKA maximum out-of-pocket cost

limitations

Qualifications that restrict the extent of the benefits. May be placed on a dollar amount, timeframe, durations, or number

exlcusions

services that will not pay

rider/endorsment

amendment/addition to an existing insurance contract which changes the terms/scope of the original policy

prior approval

Serves to determine medical necessity

appeals

request for reconsideration of coverage denial

claim

standard bill for services submitted by provider

adjunction

carrier determines reimbursement based on policy benefits

remittance advice

lists the payments for each patient during reimbursement cycle

write off

difference between actual charge/allowable charge

EOB

explanation of benefits. report sent from carrier to the insured

disability

Weekly or monthly payments for
non-working periods due to illness or injury

long term care (LTC)

fixed payments per day for SNF nursing home

medigap

Medicare supplemental insurance

property

Protects insured plant and equipment and loss of revenue due to business interruptions

liability

covers employee negligence

Health professional liability (HPL)

covers malpractice

comprehensive general liability (CGL)

covers risks resulting from public use of property

directors/officers liability

covers D&O risks

blanket crime (bonding)

covers embezzlement/employee dishonesty

errors and omission

covers non-medical professional liability like legal services

claim made policy

claim to be covered must be submitted within the policy period even though the incident did not occur within the period

occurrence policy

coverage requires the incident to have occurred during policy period even though claim was made outside