Health Insurance CH.2

  • Medical Care includes the identification of diseases and the provision of care and treatment to persons who are sick, injured, or concerned about their health status.

  • Health Care expands on medical care to include preventive services, which are designed to help individuals avoid health and injury problems.

  • Express Contract = includes provisions that are stated in the health insurance contract

  • Implied Contract = results from action taken by the health care facility or provider

  • Health Insurance = a contract between a policyholder and a third-party payer or government health program to reimburse the policyholder for all or a portion of the cost of medically necessary treatment or preventative care provider

  • Premium is the amount paid for a health insurance policy

  • Schedule of Benefits / Covered Services = outlines services covered by a health insurance plan

  • A prepaid health plan establishes a capitation contract between a managed health care plan and network providers.

  • A policyholder signs a contract with a health insurance company and owns the health insurance policy

  • An enrollee or subscriber joins a managed health care plan

  • A third-party payer is a health insurance company that provides coverage(ie. Blueshield)

  • A deductible is the amount for which the patient is financially responsible before an insurance policy provides payment

  • Copayment (copay) is a provision in a health or managed care plan that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each encounter or medical service received.

  • The Omnibus Budget Reconciliation Act of 1981 (OBRA) expanded the Medicare and Medical programs and requires providers to keep copies of government insurance claims and attachments for a period of five years

  • The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows employees to continue healthcare coverage beyond the benefit termination date by paying appropriate premiums.

  • The Patient Protection and Affordable Care Act (PPACA) focused on private health insurance reform to provide better coverage for individuals with pre-existing conditions, improve prescription drug coverage under Medicare, and extend the life of the Medicare Trust fund by at least 12 years.

  • Managed Care = a health care delivery system that is organized to manage cost, quality, and utilization

  • Managed care organization(MCO) is responsible for the health of a group of enrollees and be a health plan, health system, hospital, physician group.