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Question		Answer
staff model HMO start learning		Physicians are employees of the HMO and paid a salary
Network model start learning		the HMO contracts with at least two groups medical practices described as in network 2
independent practice Association start learning		Marcus the health plan Physicians contract with the IPA to treat members of HMO
preferred provider organization PPO start learning		a delivery Network that manages and negotiate contracts on behalf of the providers
Health maintenance organizations HMO start learning		prepaid health plan
actuary start learning		a professional who calculates insurance and annuity risks premiums and dividends
exclusive provider organizations EPO start learning		delivery Network inwhich patients must use the services of those provided
copay start learning		the out-of-pocket expense you pay the doctor
deductible start learning		the amount of money the insurer paid before the insurance company will pay
subscriber start learning		Blue Cross Blue Shield known as subscribers rather than policyholders
premium start learning		the price paid by the insured for insurance coverage
capitation start learning		payment method under which each patient is entitled to receive a set dollar amount of services in each time period
Usual fee start learning		determined by whether a provider normally charges for that service
customary fee start learning		based on fee charged buy similar providers within geographic area
reasonable fee start learning		any special circumstance of this accident
cobra. consolidated Omnibus budget reconciliation Act start learning		provides that the employee may continue to be insured through employer plan even after being fired. employee picks up total cost
ERISA. Employee Retirement income Security Act start learning		Federal legislation the mandates how employer funded benefit plans must be in administered
coordination of benefits start learning		if a service is covered under more than one policy then the insurance companies determine who pays
third-party payer start learning		insurance company, government, and Managed Care Organization
Prepaid Plan start learning		all types of health plans in which fixed payments are made before services are rendered
pre-authorization start learning		Insurance requires that certain procedures be authorized by the insurer before they are performed. failure will result in denial of claim
gatekeeping start learning		process of restricting access to services
what is the uninsured statistic start learning		45.7 million people or 17% without insurance
Indemnity insurance start learning		one-party is exempt from incurred liabilities by the other party
self-insured start learning		employer pays for Employees Healthcare
third-party admin start learning		companies that manages the paperwork for an employer who establishes a self insured plan
Managed Care start learning		describes the combination of payment for Healthcare and delivery of services into one system
what did Blue Cross Blue Shield originally cover start learning		they prepaid Baylor University 2 hospitalized for 21 days. a group of teachers
what does a self-insuring employer do start learning		the employer pays for Employees Healthcare
what percentage of Americans are covered by some type of insurance start learning		78%

Chapter 3

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