Medical Insurance Chapter 8 Quiz

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Questions and Answers

What term refers to the relationship involving the patient, physician, and health plan in medical insurance?

Indemnity Plan

Health Maintenance Organization

Third-Party Relationship (correct)

Consumer-Driven Health Plan

What are Preferred Provider Organizations (PPO)?

Managed care network of healthcare providers offering discounted fees.

What is a Health Maintenance Organization (HMO)?

A managed care organization with a narrow choice of providers and assigned primary care physicians.

In an HMO's staff model, who employs the physicians?

The organization Signup and view all the answers

What is the Group (Network) Model in HMOs?

A contract with multiple physician groups to create a network. Signup and view all the answers

What does a Point-of-Service (POS) plan combine?

HMO and PPO networks Signup and view all the answers

What are Indemnity Plans?

Fee-for-service plans requiring premium, deductible, and coinsurance payments. Signup and view all the answers

What do Consumer-Driven Health Plans (CDHP) typically combine?

High-deductible health plan and tax-preferred savings accounts. Signup and view all the answers

What is a Health Reimbursement Account (HRA)?

A medical reimbursement plan funded by an employer. Signup and view all the answers

What distinguishes Health Savings Accounts (HSA)?

They are created by individuals. Signup and view all the answers

What is the purpose of Flexible Savings Accounts (FSA)?

Funding option for medical expenses with employer and employee contributions. Signup and view all the answers

Which of the following are considered Private Insurance Payers? (Select all that apply)

Employer-sponsored medical insurance Signup and view all the answers

What does Medicare Part A cover?

Inpatient hospital care and some other services. Signup and view all the answers

What is the function of Medicare Part B?

Helps pay for physician services and outpatient care. Signup and view all the answers

What does Medicare Part D provide?

Voluntary Medicare prescription drug plans. Signup and view all the answers

What is Medicaid?

A federal and state assistance program for health care services. Signup and view all the answers

What are Third-Party Payment Methods?

Payer methods that utilize an allowed charge system. Signup and view all the answers

What is Balance Billing?

Collecting the difference between a provider's usual fee and a payer's allowed charge. Signup and view all the answers

Study Notes

Third-Party Relationships

Involves three parties: the patient (policyholder), the physician, and the health plan (third-party payer).
The health plan assumes some financial risk for healthcare services by the physician.

Preferred Provider Organizations (PPO)

A managed care network with discounted fees for services provided to plan members.
Patients can see out-of-network doctors without a referral but may face higher costs and lower reimbursement.
Encourages use of in-network providers for cost savings.

Health Maintenance Organizations (HMO)

State-licensed organizations with strict provider guidelines and limited choices.
Members must select primary care physicians (PCPs) and primarily use network providers, except in emergencies.
Offers first-dollar coverage for basic services through fixed annual premiums and copayments.
Organized into three business models: staff model, group/network model, and independent practice association model.

Staff Model

Physicians are directly employed by the HMO organization.

Group (Network) Model

Contracts with multiple physician groups to create a network of providers.

Point-of-Service (POS) Plans

Hybrid model combining aspects of HMO and PPO plans.
Slightly higher monthly premiums but allows some coverage for non-network physician visits.

Indemnity Plans

Require policyholders to pay premiums, deductibles, and coinsurance for services received.

Consumer-Driven Health Plans (CDHP)

Combines high-deductible health plans with tax-advantaged savings accounts managed by the individual.

Health Reimbursement Accounts (HRA)

Employer-funded medical reimbursement plans.

Health Savings Accounts (HSA)

Savings accounts created and funded by individuals, often used to complement high-deductible health plans.

Flexible Savings Accounts (FSA)

A funding option for consumer-driven health plans with contributions from both employer and employee.
Covers medical costs like deductibles and copayments, including expenses not covered by insurance.

Private Insurance Payers

Include employer-sponsored insurance, individual health plans, Federal Employees Health Benefits Program, self-insured plans, and Blue Cross Blue Shield Association.

Medicare Overview

Part A: Hospital Insurance, covering inpatient care, skilled nursing, home health, and hospice services.
Part B: Supplementary Medical Insurance, assisting with physician services, outpatient care, and medical supplies.
Part D: Voluntary prescription drug plans available to Medicare-eligible individuals.

Medicaid

A federal and state program providing healthcare for low-income individuals, jointly funded by both government levels.

Third-Party Payment Methods

Payment system where the payer will not reimburse more than an established allowed charge.
If a provider's fee exceeds the allowed amount, the payer pays only the allowed charge; if lower, the lesser fee is reimbursed.

Balance Billing

The practice of collecting the difference between a provider's billed charges and the payer's allowed charge.

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Description

Test your knowledge on third-party payers and their roles in the medical insurance landscape with these flashcards. This quiz covers key terms and concepts from Chapter 8, providing a comprehensive review of health plans and their relationships with patients and providers.