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

Chapter 3

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