Health Insurance and Managed Care Concepts

Overview of Health Insurance and Managed Care

Learning Objective 2.1
Summarize basic health insurance and managed care concepts.

Definition of Health Insurance

Health insurance is defined as a contract that exists between a policyholder and a third-party payer or a government health program. The purpose of this contract is to reimburse the policyholder for all or a portion of the costs associated with medically necessary treatment or preventive care provided by healthcare professionals.

Key Components of Health Insurance

  • Policyholder:
    • A policyholder is an individual who enters into a contract with a health insurance company.
    • This individual owns the health insurance policy, which provides coverage for various healthcare needs.
    • Aside from the term policyholder, the policyholder may also be referred to using various terms including:
    • Enrolled member
    • Enrollee
    • Subscriber
    • Specifically, in the context of Medicare, the term beneficiary is used instead of policyholder.
  • Coverage for Dependents:
    • The health insurance policy or plan might also include provision for coverage of dependents under the policyholder’s plan.
  • Third-Party Payer:
    • A third-party payer refers to an entity, which is typically a health insurance company, that provides coverage to policyholders.
    • Example of a third-party payer includes BlueCross BlueShield.

Content Structure of Chapters 11 to 16

Chapters 11 through 16 of this textbook cover various aspects of health insurance and government health programs, including:

  • Definitions of terms related to health insurance and managed care.
  • Instructions for completing claims.
  • Sample completed CMS-1500 claims that demonstrate professional billing processes.

Data Management in Health Insurance

  • Chapter 10 of the textbook specifically contains data that is autopopulated by an electronic health record or extracted manually by healthcare personnel.
  • This includes information pertaining to inpatient hospital admissions and outpatient hospital encounters, particularly in the context of emergency department visits.

Conclusion

Understanding these foundational concepts is crucial for navigating the complexities of health insurance and managed healthcare systems effectively, as they lay the groundwork for the more detailed discussions presented in subsequent chapters of the textbook.