Medical Insurance Chapter 4
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24 terms
Terms | Definitions |
|---|---|
 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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