Medical Insurance Ch 9

monthly enrollment list Document of eligible members of a capitated plan registered with a particular PCP for a monthly period. precertification Generally, preauthorization for hospital admission or outpatient procedure. rider Document that modifies an insurance contract. high-deductible health plan (HDHP) Type of health plan combining high-deductible insurance, usually a PPO with a relatively low premium, and a funding option to pay for patients out-of-pocket expensesup to the deductible. carve out A part of a standard health plan that is changed under a negotiated employer-sponserednplan; also refers to subcontracting of coverage by a health plan. utilization review organization (URO) Organization hired by a payer to evaluate the medical necessity of procedures before they are provided to a member of a plan. Employee Retirement Income Security Act of 1974 (ERISA) A federal law that provides incentives and protection against litigation for companies that set up employee health and pension plans. Home Plan Blue Cross and Blue Shield Plan in the community where the subscriber has contracted for coverage. Stop loss provision Protection against the risk of large losses or severly adverse claims experience; may be included in a participating provider's contract with a plan or bought by a self-funded plan. administrative services only (ASO) Contract under which a third-party administrator or an insurer agrees to provide administrative services to an employer in exchange for a fixed fee per employee. BlueCard A Blue Cross and Blue Shield program that provides benefits for plan subscribers who are away from their local areas. Blue Cross and Blue Shield Association (BCBS) The national licensing agency of Blue Cross and Blue Shield plans. Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law requiring employers with more than twenty employees to allow employees who have been terminated for reasons other than gross misconduct to pay for coverage under the employer's group health plan for 18 months after termination. credentialing Periodic verification that a provider or facility meets professional standards of a certifying organization; physician credentialing involves screening and evaluating qualifications and other credentials, including licensure, required education, relevant training and experience, and current competence. creditable coverage History of health insurance coverage for calculation of COBRA benefits. discounted fee-for-service A negotiated payment schedule for health care services based on a reduced percentage of a provider's usual charges. elective surgery Nonemergency surgical procedure that can be scheduled in advance. episode of care (EOC) Option A flat payment by a health plan to a provider for a defined set of services, such as care provided for a normal pregnancy, or for services for a certain period of time, such as hospital stay. family deductible Fixed, periodic amount that must be met by the combination of payments for covered services to each individual of an insured/dependent group before benefits from a payer begin. Federal Employees Health Benefits (FEHB) program The health insurance program that covers employees of the federal program. Flexible Blue The Blue Cross and Blue Shield consumer-driven health plan. flexible savings account (FSA) Type of consumer driven health funding plan option that has employee contributions; funds left over revert to the employer. formulary A list of a health plan's selected drugs and their proper dosages; often a plan pays only for the drugs it lists. group health plan (GHP) Under HIPAA, a plan (including a self-insured plan) of an employer or employee organization to provide health care to the employees, former employees, or their families. Plans that are self-administered and have fewer than fifty participants are not ________ plans. health reimbursement account (HRA) Type of consumer-driven health plan funding option under which an employer sets aside an annual amount an employee can use to pay for certain types of health care costs. health savings account (HSA) Type of consumer-driven health plan funding option under which employers, employees, both employers and employees, or individuals set aside funds that can be used to pay for certain types of health care costs. host plan Participating provider's local Blue Cross and Blue Shield plan. independent practice association (IPA) Type of health maintenance organization in which physicians are self-employed and provide services to both HMO members and nonmembers. individual health plan (IHP) Medical insurance plan purchased by an individual, rather than through a group affiliation. individual deductible Fixed amount that must be met periodically by each individual of an insured/dependent group before benefits from a payer begin. late enrollee Category of enrollment in a commercial health plan that may have different eligibility requirements. maximum benefit limit The amount the insurer agrees to pay for an insured covered expenses over the course of the insured person's lifetime. open enrollment period Span of time during which a policyholder selects from an employer's offered benefits; often used to describe the 4th qtr of the year for employees in employer-sponsored health plans or the designated period for enrollment in a Medicare or Medigap plan. parity Equal in value. pay-for-performance (P4P) Health plan financial incentives program to encourage providers to follow recommended care management protocols. plan summary grid Quick reference table for frequently billed health plans. repricer Vendor that processes out-of-network claims for payers. Section 125 cafeteria plan Employer's health plans that are structured under income tax laws to permit funding of premiums with pretax payroll deductions. silent PPO's Managed care organization that purchases a list of a PPO's participating providers and pays those provider's claims for its enrollees according to the contract's fee schedules even though the providers do not have contracts with them. A provider can avoid having to work with them by making sure his or her contract includes language prohibiting the PPO from selling his or her name to another party. subcapitation Arrangement under which a capitated provider prepays an ancillary providor for specified medical services for plan members. Summary Plan Description (SPD) Legally required document for self-funded plans that states beneficiaries benefits and legal rights. Third-party claims administrator (TPAs) Company the provides administrative services for health plans but is not a contractural party. tiered network Plan feature that pays more to providers that the plan rates as providing the highest quality, most cost effective medical services. utilization review Payer's process to determine the appropriateness of hospital-based health care services delivered to a member of a plan. waiting period Time period between an insured's date of enrollment and the date insurance coverage is effective. Federal Employees Health Benefit Program What is the largest employer-sponsored health program in the United States? Open Enrollment period In employer-sponsored health plans, employees may choose their plan during the? COBRA & HIPAA The portability of health insurance is governed by which laws? ERISA Self-funded health plans are regulated by? All Major types of health plans Blue Cross and Blue Shield Assoc member plans offer which type of plans? Precertification (preauthorization) within a specified time after the procedure. Emergency surgery usually requires? A discounted-fee-for-service Providers who participate in a PPO are paid based on? A monthly enrollment list Under a capitated HMO plan, the physician practice receives from the payer each month? participation contract What document is researched to uncover rules for private payers' definitions of insurance related terms? A high deductible payment from the patient takes longeer to collect than does a copayment. Consumer-driven health plans have what effect on a practice's cash flow?