Dynamics of Health care - Chapter 19 Health Insurance

co-insurance

the term used to describe plans that require the insured to share a portion of the costs for health care services

co-pay

a flat fee each time you receive a health care service

deductible

the money a person pays before the insurance policy provides benefits (a yearly cost)

DRGs (diagnostically related groups)

a classification system used by Medicare and Medicaid to determine payment for health services

direct payment

patient pays for their health care with their own money

(EPO) Exclusive Provider Organization

a hybrid health insurance plan in which a primary care provider is not necessary, but health care providers must be seen within a predetermined network

- no referral

- low premiums

- high deductible

(FSA) Flexible Spending Account

offered through an employer and is usually paired with a traditional health insurance policy

Gatekeeper

A primary physician who not only delivers primary care services but also makes referrals for specialty care and coordinated the health care services of the patient

Government Institution

Public health facilities that receive most of its funding from local, state, or federal sources

Government plan

a health care plan funded by a government agency

Health care cost containment

aim to create an affordable health care system for all Americans

(HMO) Health Maintenance Organization

this plan provides coverage only if the care is delivered by a member of its hospital, physician, or pharmacy panel

- referrals

- wont pay for outside of plan treatment

(HSA) Health savings account

Commonly paired with a high-deductible health insurance plan-a plan that offers low monthly premiums, but requires the insured to pay a high deductible

In-network provider

one contracted with the health insurance company to provide services to plan members (providers in the plan)

Managed care

puts health care providers in the position of managing a patient's use of health care

- PROVIDES PREVENTATIVE HEALTH SERVICES

Medicaid

offers health insurance to many low-income and disabled people

Medicare

provides health care coverage for geriatrics (ages 65 and older) regardless of income or wealth

Out-of-network provider

one not contracted with the health insurance plan (providers outside of the network)

(POS) Point-of-service plan

this is a physician-coordinated plan that combines characteristic of both HMO and PPO plans

- no deductible

- referrals

(PPO) Preferred provider organization plan

this plan allows patients to receive care from a non-plan provider, but required them to pay a higher out-of-pocket price if they do so

- no referrals

- higher premiums

- costs more if out of plan

Premium

monthly amount paid to an insurance company for health insurance coverage

Private insurance

primarily an employment-based health insurance system

Proprietary institution

a for-profit facility usually owned by a corporation. They must pay local, state, and federal taxes

Prospective payment system

a system that pays the provider a fixed amount that is based on the medical diagnosis or specific procedure, rather than the cost of hospitalization or care

Resource utilization

health care workers asking themselves how they can best use health care resources

TRICARE

provides medical coverage for active and retired service personnel and their dependents

Utilization review

process in which an insurer reviews decisions by physicians and other providers about how much care to provide

Voluntary nonprofit institution

A community facility that receives federal tax exemptions in exchange for providing a community benefit

CIRPA

funds for uninsured children

primary care physician

help patients maintain overall health by focusing on preventative care

Pre-authorization

insurance company determining whether or not a certain procedure is necessary, usually depending on money they will decide if they will pay for it

what is the income for the insurance company?

premiums

if one monthly payment is missed the insurance company ________

drops your coverage

Traditional Indemnity Health Insurance Plans

or

fee-for-service

Medicare part a

pays for hospitalization cost

Medicare part B

pays for doctor visits and outpatient cost

Medicare part c

Medicare Advantage Plans, optional

Medicare part D

pays for prescription drug costs

HMO advantages and disadvantages

Advantages:

low out of pocket cost

focuses on wellness and preventative care

Disadvantages:

Referrals

PPO advantages and disadvantages

Advantages:

No referrals

PCP not required

more choices of doctors

Disadvantages:

Higher premiums

POS advantages and disadvantages

Advantages:

MAXIMUM FREEDOM

minimal co-pay

no deductible

no gatekeeper

Disadvantages:

referrals

EPO advantages and disadvantages

advantages:

low monthly premiums

no referral

disadvantages:

high deductibles

care outside of network is not covered unless its an emergency

For traditional/ Indemnity care you will be billed based on...

UCR's (usual, customary, and reasonable fees)

Traditional/Indemnity care advantages and disadvantages

advantage:

freedom to choose health care facility with no restrictions

disadvantage:

cost of services are higher

more paperwork involved

most common medical savings account

FSA

What happens to the money in your FSA at the end of the year?

they're forfeited

What happens to your money in your HSA at the end of the year?

its rolled over

at 65 you can take money out of which account to use however?

HSA (health savings account)

resource utilization requires:

time management

use of electronic documentation

the 2 major factors causing a rise in health care costs:

rising drug, technology, and professional costs

aging population

reimbursement

the action of repaying a person who has spent or lost money