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

Chapter 3

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