group health insurance 192
Health insurance consisting of contracts written between a group, (employer, union, etc.) and the healthcare provider.
indemnity (fee-for-service) plan 192
health insurance plan in which the health care provider is separate from the insurer, who pays the provider or reimburses you for a specified percentage of expenses after a deductible amount has been met.
managed care plan193
A health care plan in which users contract with the provider organization, which uses a designated group of providers meeting specific selection standards to furnish health care services for a monthly fee
health maintenance organization ( HMO) 193
is a managed care benefits plan that provides a wide range of medical services to individuals that have been enrolled into the program. It is generally the least costly but at the same time also the most restrictive. This plan uses a gatekeeper physician
group HMO 194
An HMO that provides health care services from a central facility; most prevalent in larger cities.
individual practice association (IPA) 194
a type of HMO that contracts with groups of physicians who practice in their own offices and receive a per-member payment (capitation) from participating HMOs to provide a full range of health services for members
preferred provider organization (PPO) 194
A health care provider that combines the characteristics of an
IPA form of HMO with an indemnity plan to provide comprehensive health care services to its subscribers within a network of physicians and hospitals.
exclusive provider organization (EPO) 194
A type of managed health care plan that combines features of HMOs and PPOs. It is referred to as "exclusive" because it is offered to large employers who agree not to contract with any other plan. EPOs are regulated under state health insurance laws.
point-of-service (POS) plan 194
A "hybrid" type of managed care, also referred to as an open-ended HMO, that allows patients either to use the health maintenance organization provider or to go outside the pan and use any provider they choose
blue cross/blue shield plan 194
Blue Cross - is designed for hospital benefits
Blue Shield - is designed for physicians
- operate in limited geographic areas
- Not all hospitals except BCBS
- operate on a sevice basis
- was established as a non profit service organization
- premiums are
medicare 195
a health insurance program provided by the US government for older Americans who have sufficient money to pay for part of their health care costs, Enacted in 1965 - provided, under Social Security, for federal subsidies to pay for the hospitalization of s
supplementary medical insurance (SMI) 196
A voluntary portion of Medicare coverage that pays 80 percent of the reasonable charges for covered medical services (such as physicians' and surgeons' services and supplies, and outpatient physical and occupational therapy services) after a $100 deductab
prescription drug coverage 196
A voluntary program under Medicare (commonly
called Part D) that is insurance covering both brandname and generic prescription drugs at participating pharmacies. Participants pay a monthly fee and a yearly deductible and must pay
part of the cost of presc
medicaid 196
state and federal public-assistance program that helps pay health care costs for low-income and disabled persons
workers compensation insurance 196
A state or federal plan that covers medical care and other benefits for employees who suffer accidental injury or become ill as a result of employment.
health reimbursement account (HRA) 197
an account into which an employer puts money to reimburse employees for qualified medical expenses
health savings account (HSA) 197
a tax deductible savings account into which individuals and/or their own employees can deposit tax sheltered funds for use to pay medical bills including the deductibles and out of pocket costs required by a high deductible plan.
major medical plan 201
Developed from basic hospital expense policies as a result of increased sophistication and expense involved with medical procedures and techniques. Designed to provide protection against catastrophic loss.
comprehensive major medical insurance 201
Designed to give the protection offered by both a basic medical expense and major medical policy. It is characterized by a low deductible amount, coinsurance clause, and high maximum benefits.
deductible
Amount you have to pay out-of-pocket for expenses before the insurance company will begin to cover all or a portion of the remaining costs.
participation (coinsurance) clause 202
a provision in many health insurance policies stipulating that the insurer will pay some portion�say 80-90%--of the amount of the covered loss in excess of the deductible.
� Helps reduce the possibility that policyholders will fake illness and discourage
internal limits 202
A feature commonly found in health insurance policies that places a constraint on the amount that will be paid for specified expenses, even if the overall policy limits are not exceeded by a
given claim
coordination of benefits provision 202
A provision in a group medical expense policy designed to prevent a group insured who is insured under more than one group medical expense insurance policy from receiving benefit amounts that are greater than the amount of medical expenses the for up insu
preexisting condition clause 203
a clause included in most individual health insurance policies permitting permanent or temporary exclusion of coverage for any physical or mental problems the insured had at the time of the policy was purchased.
health insurance portability and accountability act (HIPPA) 203
A federal statute that helps workers keep continuous health insurance coverage for themselves and thier dependents when they change jobs, protects confidential medical information from unauthorized disclosure or use, and helps curb the rising cost of frau
long-term care 205
Range of medical care to assist persons with disability or chronic care needs. Provides 24 hours a day care for long period of time. Skilled nursing facility for severely disabled.
waiting (elimination) period 207
the period after an insured meets the policy's eligibility requirements, during which he or she must pay expenses out-of-pocket; the waiting period expires, the insured begins to receive benefits.
guaranteed renewability 207
the insurer cannot cancel the policy unless you fail to pay the premiums; it also forbids insurers from raising your premiums unless they raise all premiums for all members of your group
optional renewability 207
Contractual clause allowing the insured to continue insurance only at the option of the insurer
disability income insurance 208
Insurance that provides families with weekly or monthly payments to replace income when the insured is unable to work because of a covered illness, injury, or disease.