Category 1: Insurance Basics
This is the monthly amount you pay to keep your insurance active.
What is a premium?
This document explains what your insurance paid and what you owe.
What is an Explanation of Benefits (EOB)?
This Medicare part covers hospital stays.
What is Part A?
This program provides coverage based mostly on income level.
What is Medicaid?
In this type of health plan, patients usually choose a primary care provider and need referrals before seeing specialists.
What is an HMO (Health Maintenance Organization)?
This is the amount you must pay before insurance starts covering services.
What is a deductible?
This notice is given to Medicare patients BEFORE a service is provided to inform them that Medicare may not cover it and they may have to pay themselves.
What is an Advance Beneficiary Notice (ABN)?
This Medicare part covers doctor visits and outpatient care.
What is Part B?
This group is one of the most common populations covered by Medicaid.
Who are low-income individuals and families?
This type of health plan allows patients to see specialists without referrals but usually costs more than an HMO.
What is a PPO (Preferred Provider Organization)?
This is a fixed amount you pay for a doctor visit or prescription, such as $25 per visit.
What is a copay?
This document is sent to Medicare patients after services are provided and explains what Medicare paid, what it did not pay, and what the patient may still owe.
What is a Medicare Summary Notice (MSN)?
This Medicare option replaces traditional Medicare through private insurers.
What is Part C?
This service is often covered by Medicaid to help patients travel to appointments.
What is non-emergency medical transportation?
In this managed care model, physicians are employees of the insurance organization and provide care in plan-owned facilities.
What is the staff model?
This is the percentage you pay after meeting your deductible.
What is coinsurance?
This document is sent to healthcare providers by insurance companies to explain how a claim was processed and why payments were approved, reduced, or denied.
What is a remittance advice?
This Medicare part helps cover prescription medications.
What is Part D?
Children in families who earn too much for Medicaid may qualify for this related program.
What is CHIP?
In this managed care model, the insurance plan contracts with one large physician group to provide care for its members.
What is the group model?
This is the most you will have to pay for covered healthcare services in a year before your insurance pays 100% of covered costs.
What is the out-of-pocket maximum?
This happens when an insurance company refuses to pay for a service because it was not covered, not medically necessary, or missing authorization.
What is a claim denial?
People age 65 and older typically qualify for this federal insurance program.
What is Medicare?
Patients enrolled in Medicaid often must choose this type of provider who coordinates their care and referrals.
What is a primary care provider (PCP)?
This managed care model allows doctors to keep their own private practices while agreeing to treat plan members at negotiated rates.
What is an IPA model (Independent Practice Association)?