Medical Insurance Chapter 4

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assignment of benefits

The authorization by a patient to the insurer to make payments for covered services directly to the provider.

catastrophic coverage

The catastrophic coverage portion of a consumer-driven health plan; covers expenses for catastrophic illnesses or accidents that go beyond the scope of what is covered by basic insurance or the funds available in arrangement agreements.

Medigap

Coverage that helps pay for the deductible, co-insurance, and other "gaps" in coverage in the Medicare plan.

closed panel HMO

An HMO that contracts with physicians to exclusively provide services to its members. Physicians are employees of the HMO and are not allowed to see patients from other managed care plans.

CMS

Acronym for the Centers for Medicare & Medicaid Services.

consumer-driven health plans

Medical insurance plans that give patients the ability to see any doctor without requiring approval from a primary care physician (PCP). These are the least restrictive health plans in terms of services, but they require patients to manage how their health care dollars are spent.

FSA

Acronym for Health Flexible Spending Account.

group model HMO

An HMO that resembles the closed panel model, but instead of contracting with individual physicians, it contracts with medical group practices.

group plan

The most common type of health insurance; a single medical plan provides coverage for a group of people, such as employees or members of an organization.

HCFA

Acronym for the Health Care Financing Administration, the forerunner of CMS.

Health Maintenance Organization (HMO)

A type of managed care plan that generally requires the patient to have a primary care physician (PCP) who provides routine medical care and authorizes the patient to see specialists; also known as a Managed Care Organization (MCO).

HRA

Acronym for Health Reimbursement Arrangement.

indemnity plan

A health insurance plan that gives a patient the most choices (has the fewest restrictions) but places the responsibility of financial management on the patient; sometimes called traditional or commercial insurance.

individual plan

A medical insurance plan that is purchased directly by the policyholder.

in-network

Term used to describe medical services received from a physician who is part of an HMO network of providers.

major medical

The catastrophic coverage portion of a consumer-driven health plan; covers expenses for catastrophic illnesses or accidents that go beyond the scope of what is covered by basic insurance or the funds available in arrangement agreements.

managed care

A system of health plans that attempts to control costs by limiting access to health care and focusing on preventive medicine.

Medicare + Choice

A type of plan that must provide all the coverage available with the original Medicare and may even offer additional services not covered by the original Medicare; also known as Medicare Part C.

MSA

Acronym for Medical Savings Account.

open panel HMO

An HMO in which physicians provide services to plan enrollees in their own offices. The physicians are not employees of the HMO.

Participating Provider Organizations (PPOs)

Physicians and facilities, such as hospitals, that have agreed to provide services to patients on a discounted fee schedule.

Provider Sponsored Organization (PSO)

A single provider or a group of affiliated providers who provide services to beneficiaries. The physicians and hospitals of PSOs take the financial risk of providing health benefits directly to the enrolled beneficiaries.

staff model HMO

See closed panel HMO. The term "staff model" is derived from the fact that the physicians are employees of the HMO and are therefore on the staff of the HMO.

usual, customary, and reasonable (UCR)

A system for tracking data related to procedure fees charged and payments accepted by physicians. The system considers geographic location and other relevant factors.

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