Health Insurance Terms Flashcards

Health Insurance Terms

• Coinsurance: A cost-sharing method where the insured pays a percentage of medical expenses after the deductible is met.

• Copayment: A fixed dollar amount paid by the insured for medical services, with the insurer covering the remaining costs.

• Deductible: A predetermined amount paid by the insured before insurance coverage kicks in, applicable to individual or family plans.

• Flexible Spending Accounts (FSA): Employer-administered accounts allowing employees to set aside pretax earnings for medical expenses or premiums.

• Indemnity Plan: A medical plan that reimburses costs incurred by the patient or provider as they occur.

• Conventional Indemnity Plan: A type of indemnity plan allowing choice of any provider without affecting reimbursement rates.

• Preferred Provider Organization (PPO): An indemnity plan offering coverage through a network of selected healthcare providers.

• Exclusive Provider Organization (EPO): A restrictive plan requiring members to use a specific network of providers for coverage to apply.

• Health Maintenance Organization (HMO): A system that assumes financial risk and responsibility for healthcare delivery within specific geographic areas for its members.

• Group Model HMO: Contracts with a multi-specialty medical group to provide care for HMO members, serving both HMO and non-HMO patients.

• Staff Model HMO: A closed-panel HMO where physicians are employees, limiting patient services to a small provider network.

• Network Model HMO: Contracts with multiple physician groups to deliver services to HMO members, comprised of large single and multispecialty groups.

• Individual Practice Association (IPA) HMO: Composed of independent physicians offering services to HMOs while maintaining their own practices.

• Point of Service (POS): A hybrid HMO/PPO plan, resembling HMO coverage for network services, with indemnity-like reimbursement for out-of-network services.

• Physician Hospital Organization (PHO): Collaboration between physicians and hospitals to enhance market share, bargaining power, and reduce costs.

• Managed Care Plans: Comprehensive health services with financial incentives for members to utilize plan-associated providers.

• Maximum Plan Dollar Limit: The insurer's cap on the amount payable for covered expenses during the coverage period.

• Maximum Out of Pocket Expense: The highest amount members must pay themselves during a year before the insurance covers additional costs.

• Medical Savings Accounts (MSA): Accounts for out-of-pocket medical expenses funded with pre-tax contributions, allowing for fund carryover year to year.

• Premium: Agreed-upon fees for medical benefit coverage, payable by employers, unions, or shared by both parties involved.

• Premium Equivalent: Cost for self-insured plans reflecting anticipated claims, administrative costs, and stop-loss premiums.

• Primary Care Physician (PCP): The main healthcare provider for managed care members, coordinating services and referrals.

• Self-Insured Plan: Health insurance offered by employers who directly cover the significant costs of employee health care.

• Third Party Administrator (TPA): An external firm managing claims processing, payments to providers, and insurance operations without being the insurer.

• Exclusive Providers: Plans mandating the use of specific providers for coverage of non-emergency services.

• Any Providers: Allows members unrestricted choice in provider selection without cost incentives for specific groups.

• Usual Customary Reasonable Charges (UCR): A billing approach for conventional indemnity plans based on typical fees for services in a geographic area.