Terminology
Protect wage earners against the loss of wages and the cost of medical care resulting from occupational accidents and diseases.
What is Workers Compensation
Offered to all medicare recipients to cover the cost of their prescription drugs.
What is Medicare Part D
A state to state health benefits program designed for low income people, and those who are blind, disabled, members of families with dependent children deprived of the support of at least one parent.
What is Medicaid.
A standard designed to protect medical records and all personal health information.
What is the Health Insurance Portability and Accountability Act
The Medicare rule that determines who pays the members claim
What is " who pays first"
When are you Medicare eligible but still working for a company with over 20 employees who pays your claims first?
The employer's plan sits primary for companies with over 20 employees
To enroll you must be under 30 years old OR qualify for a "hardship" or "affordability" exemption if you're over 30.
What is a catastrophic health plan
A managed care organization developed to control the expenditure of health care dollars and to manage patient care.
What is a Health Maintenance Organization
A plan designed for people with specific chronic illnesses
What is a special needs plan /SNP
When an insurer determines whether an insurance claim is correct and able to be paid, and if so makes payment.
What is Claims Adjudication
The kind of arrangement that allows an employer to pay for individual coverage
What is an ICHRA or QSHRA
A plan where all services besides annual preventative are not covered until after a designated high deductible is satisfied
A qualified HDHP
This plan has a " use it or lose it" feature
A flexible spending account or F.S.A.
A plan that covers medical expenses around the world
What is Global Health Insurance
Inpatient health care services, services in hospitals, nursing facilities, home health care, and hospice care.
What is Medicare Part A
A plan for men and women who are veterans
What is the VA
Medicare Part B coverage requires you to use this universal claim form.
What is a CMS 1500
When you get this, your insurer has paid less than 85% of your premiums on claims.
What is the Medical Loss Ratio rebate or MLR
A plan where the employer or administrator designates the health care payments not a PPO contract
Reference based pricing
The amount you pay each month to belong to a health plan.
What is a Premium?
Enrollees receive the highest level of benefits when they obtain services from a health provider designated by their program as a preferred provider.
What is a Preferred Provider Organization
This plan requires members to replace original medicare and enroll with a private compant
What is Medicare Part C or Medicare Advantage
The intentional misrepresentation that results in unauthorized benefits to an individual or organization.
What is Health Insurance Fraud
If you qualify for this you must be enrolled on a SILVER plan in the marketplace
What is the CSR or Cost Sharing Reductions
An arrangement through the employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. You aren't taxed on this money.
A flexible spending account or FSA
Medicare is a program authorized by Congress and administered by this group.
What is Centers for Medicare & Medicaid Services
You may qualify for this to help cover insurance premiums
What is the advanced premium tax credit
If you company pays this annual fee per member, the plan offered can only be a self-insured plan.
What is the PCOR fee
When you reach this, your in-network covered claims are paid for at 100% by your insurer.
What is your Max out of Pocket or MOOP