Health Insurance Terms Flashcards

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Questions and Answers

What is coinsurance?

Accounts set up for pre-tax dollars for medical expenses

A fixed dollar amount paid when a service is received

A type of health care system

A form of medical cost sharing that requires an insured person to pay a stated percentage of medical expenses (correct)

What is a copayment?

A fixed dollar amount paid when a medical service is received.

What is a deductible in health insurance?

A fixed dollar amount paid before the insurer starts covering medical expenses.

What does FSA stand for?

Flexible Spending Accounts. Signup and view all the answers

What is an indemnity plan?

A type of medical plan that reimburses expenses as they are incurred. Signup and view all the answers

What distinguishes a conventional indemnity plan?

It allows the participant to choose any provider without affecting reimbursement. Signup and view all the answers

What is a Preferred Provider Organization (PPO)?

An indemnity plan providing coverage through a network of selected providers Signup and view all the answers

An Exclusive Provider Organization (EPO) allows patients to use providers outside its specified network.

False Signup and view all the answers

What does HMO stand for?

Health Maintenance Organization. Signup and view all the answers

What is a Group Model HMO?

An HMO that contracts with a single multi-specialty medical group. Signup and view all the answers

What is a Staff Model HMO?

A closed-panel HMO where physicians are employees of the HMO. Signup and view all the answers

What is the Network Model HMO?

An HMO that contracts with multiple physician groups for services. Signup and view all the answers

What is an Individual Practice Association (IPA) HMO?

A group of independent physicians who maintain their own offices. Signup and view all the answers

What is a Point of Service (POS) plan?

An HMO/PPO hybrid that resembles HMO services for in-network care. Signup and view all the answers

What does PHO stand for?

Physician Hospital Organization. Signup and view all the answers

What do managed care plans offer?

Comprehensive health services with financial incentives to use network providers. Signup and view all the answers

What is the maximum plan dollar limit?

The maximum amount payable by the insurer for covered expenses. Signup and view all the answers

What is the maximum out-of-pocket expense?

The maximum dollar amount a group member must pay in a year. Signup and view all the answers

What are Medical Savings Accounts (MSAs)?

Savings accounts for out-of-pocket medical expenses. Signup and view all the answers

What is a premium in health insurance?

Fees paid for coverage of medical benefits. Signup and view all the answers

What is a premium equivalent?

The cost per covered employee in self-insured plans. Signup and view all the answers

What is a Primary Care Physician (PCP)?

The physician who serves as a primary contact in a health plan. Signup and view all the answers

What is a self-insured plan?

A plan where employers assume major health insurance costs. Signup and view all the answers

What does a Third Party Administrator (TPA) do?

Handles claims processing and other health insurance functions. Signup and view all the answers

All enrollees in a health plan can go to any provider without restrictions.

False Signup and view all the answers

What are usual customary reasonable charges (UCR)?

Charges that reflect the typical medical fees in a geographic area. Signup and view all the answers

Study Notes

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.

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Description

This quiz features flashcards that cover essential health insurance terms, such as coinsurance and copayment. Perfect for anyone looking to enhance their understanding of health insurance concepts and terms. Test your knowledge and improve your familiarity with medical cost sharing structures!