Plans
Terminology
More Terminology
More Terminology II
and More Terminology
100
A PCP is not required in this type of plan. The plan also provides for In-Network and Out of Network Benefits
What is PPO
100
Providers that have agreed to accept insured members as patients and also agree to accept the usual & customary amount as payment in full.
What are In-Network providers
100
The term used when an OON provider has not agreed to accept a negotiated rate as payment in full, and the provider has the right to bill the member for the difference between what the insurer pays and what the provider billed for the service.
What is Balance Billing
100
Certain medical services/treatment not covered under a plan per the member's employer group.
What are Contractual Exclusions
100
An amount of money that a person with health insurance is required to pay at the time of each visit to a doctor or when purchasing medicine
What is a co-pay
200
Members must select a primary care physician (PCP) who coordinates the member’s care, sometimes referred to as a gatekeeper.
What is HMO (and POS)
200
The broad range of people and facilities that provide health care services.
What are providers
200
The dollar amount the member must pay for health care services before the company will begin to pay for any of those services.
What is deductible
200
The _______ is the employee who has insurance through their employer.
What is a member (or subscriber, policy holder)
200
A co-sharing agreement between the insured and the insurer under a health insurance policy which provides that the insured will cover a set percentage of the covered costs after the deductible has been paid
What is co-insurance
300
Care is covered only if the member sees a provider in the PPO network.
What is EPO
300
The term used to describe a client who pays a specific amount of money to Anthem through the payment of premiums. Anthem uses this money to pay for both the health care services covered under the terms of the contract and to pay for the administrative cost to manage the program.
What is Fully Insured
300
The prevailing rate is the average or typical cost for a service in a geographic area.
What is Usual and Customary
300
another term for subscriber
What is policy holder (or member)
300
Are those whom the subscriber elects to include in the insurance plan (i.e. spouse, children)
What are dependents
400
A plan that typically covers any medical service at an agreed to percentage – typically at 70/30%.
What is an Indemnity Plan
400
the term used to define clients who pay Anthem a fee to handle only the administrative work of processing health benefit claims. The client pays for the cost of the health care services provided to its members.
What is Administrative Services Only or ASO
400
When a member follows the terms of the contract by using in-network providers and obtaining required authorization for services, they can not be balance billed because they are _______
What is Held Harmless (or not Liable)
400
The hybrid plan of the HMO which offers an OON option is the:
What is a POS
400
Are businesses, organizations, government agencies, or companies who purchase insurance coverage for their employees.
What are employer groups
500
A managed care program that puts the member in the driver’s seat with tools and additional information to make informed decisions about how and where to spend and earn their health care dollars
What is Consumer Driven (or Directed) Health Plan and/or High Deductible Health Plan
500
Clients with 2,500 or more eligible employees (both active and retired) of whom more than five (5) percent of the population lives outside of the state where the company is headquartered.
What are National Accounts
500
This consideration allows a provider to be treated as an in-network provider for a specific medical service under special circumstances such as network inadequacy, lack of bed availabilitiy, certain specialties
What is IFO or In for Out
500
Name 3 rules required by the HMO plan
What is: The member must have a PCP, referral from PCP to see a specialist are required, and limited to utilization of HMO network providers only
500
Was enacted to increase the quality and affordability of health insurance, lower the uninsured rate by expanding public and private insurance coverage, and reduce the costs of healthcare for individuals and the government.
What is Affordable Care Act
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