Health Insurance Providers Chapter 5

Study Notes

Health Insurance Providers Overview

Commercial Health Policies: Allows policy owners to assign benefits directly to healthcare providers; includes pre-paid health plans with specific benefits and monthly payments.
Capitation: A fixed payment made to a physician for each member enrolled in a Health Maintenance Organization (HMO).
Gate Keeper System: A system where subscribers select a primary care physician who manages all their healthcare needs.

Medicare Insights

Medicare: Provides medical services for individuals aged 65 and older, those with chronic kidney disease, and recipients of Social Security Disability for at least 24 months. Covers hospital room and board, physician services, and prescription drugs.
Medicare Part B Funding: Mostly funded by general tax revenue and user premiums, with 80% coverage for physician fees.
Medicare Assignment: Physicians accepting Medicare Assignment agree to charge no more than the Medicare-approved amount for services, covering 80% of costs with beneficiaries responsible for 20% after the deductible.
Supplementary Medical Insurance: Another name for Medicare Part B.

Medicaid and Employer Plans

Medicaid: Designed to assist individuals in poverty, providing financial support for various health services.
MEWA (Multiple Employer Welfare Arrangement): Allows small employers to sponsor group benefits for their employees through an insurer.

Preferred Provider Organizations (PPO)

Out-of-Network Coverage: When PPO insured individuals seek care outside the network, their insurer pays a reduced amount for services rendered.

Description

Explore key terms from Chapter 5 on health insurance providers with these flashcards. Learn about commercial health policies, capitation, and the gatekeeper system in health care. This quiz will enhance your understanding of health care payment structures.