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

Chapter 3

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