Major Insurances
This insurance is only for individuals aged 65+, younger people with certain disabilities, those with end-stage renal disease. You must have worked and paid Medicare taxes for 10 years to be eligible.
What is Medicare?
The amount that is paid each pay period for your health insurance. Usually deducted from your paycheck.
What is a premium?
A physician you choose who provides both first contact and a continuing care for a variety of medical conditions.
What is a PCP (primary care physician)?
The amount the insurance carrier will pay for a particular service.
What is the allowed amount? (allowable fee)
a physician’s list of their charge for each service they provide
What is a fee schedule?
In Medicare, the name for the policyholder (because no dependents are allowed on Medicare plans)
What is a beneficiary?
An electronic or paper-based report of payment sent by the payer to the provider.
What is a remittance advice?
This insurance is for people with low income who may not be able to afford insurance on their own.
What is Medicaid?
The out-of-pocket amount you pay before insurance pays expenses.
What is a deductible?
The name of the person who "owns" the insurance policy.
Who is a policyholder?
This is when employers pay directly for employees’ medical bills
What is self-insure?
The federal tax identification number for a business:
What is an EIN (employer identification number)?
The name of the required form that a patient must sign before receiving any treatments that are not covered by Medicare.
What is an ABN (advanced beneficiary notice)?
When your insurance requires that you get permission before a particular healthcare service (such as a surgery) can be provided, this is called:
What is preauthorization (or prior authorization)?
This insurance is for individuals who have been hurt, injured, or become sick due to their job duties, whether it happened directly on the job, or just was the result of their normal regular job duties.
What is workers' compensation?
This is a fixed out-of-pocket amount you pay for covered services. You may have a certain amount for your PCP, a certain amount for a specialist provider, a certain amount for the ER, etc.
What is a co-pay?
When a provider agrees to accept the allowed amount that the insurance is willing to pay on their fee schedule.
What is accepting assignment?
This type of insurance plan has stringent guidelines and a narrow choice of providers. Typically need authorization before a procedure will be covered. All care must run through the PCP for any referrals
What is an HMO? (health maintenance organization)
This form is filled out at each patient visit by the provider. It is a listing of the diagnosis, procedures, and charges for a patient’s visit.
What is an encounter form (or superbill in an inpatient setting)?
This part of Medicare covers the cost of prescription drugs. Part _____
What is Part D?
Medicare and Medicaid are run through this federal agency:
What is the Centers for Medicare and Medicaid Services (CMS)?
This insurance was the first private commercial insurance. It was started at Baylor University, and is now the largest health insurance company (exists in all 50 states)
What is BlueCross BlueShield?
A percentage of costs you pay after your deductible is met. Usually 20% or 30%
What is a co-insurance?
A statement signed by the patient authorizing the provider to be paid directly by the patient’s insurance company.
What is assignment of benefits?
In this type of health insurance plan, the patient pays an annual premium and often a deductible. Could have a low premium with a high deductible or vice versa. May see an out-of- network doctor without a referral or preauthorization, but the deductible may be higher
What is a PPO? (preferred provider organization)
These accounts designed to pay for qualified medical expenses of individuals who have high deductible health plans and are under the age of 65.
What is an HSA? (health savings account)
This part of Medicare is supplementary medical insurance that helps pay for physician services (outpatient care) and is through voluntary enrollment
What is Part B?
Medicare Supplemental insurance, is health coverage to fill in the “gaps” that Medicare Part A and Part B can leave.
What is Medigap insurance?
This insurance plan is for active duty military and their family members, retirees, and their families.
What is Tricare?
A predetermined amount a covered individual must reach before insurance pays 100% of eligible medical expenses.
What is an out-of-pocket maximum?
What is the process of decision which insurance must pay first, when a policyholder has more than one insurance plan?
What is coordination of benefits?
This insurance plan is is a combination of an HMO and a PPO
What is a point-of-service (POS) plan?
This account allows employees to put pre-tax dollars from their salaries into it; then they can use the funds to pay for certain medical expenses.
What is an FSA? (flexible spending account)
This part of Medicare covers inpatient hospital stays. Also known as original Medicare.
What is Medicare part A?
This type of payment method is where the provider is paid a flat fee per person that is enrolled in the healthcare plan:
What is capitation?
This insurance plan is for veterans who are permanently disabled as a result of service-connected conditions or injuries, (or for their widows or dependents of such veterans).
What is CHAMPVA?
Aa statement provided by your health insurance company explaining how medical treatments and services were paid. This is sent to the PATIENT/POLICYHOLDER
What is an EOB (Explanation of benefits)?
A statement provided by a health insurance company to the PROVIDER explaining how medical treatments and services were paid. It will give a reason for any services on the claim form that were denied.
What is a remittance advice?
This type of insurance plan combines a high deductible health plan with one or more tax-preferred savings accounts that the patient directs.(such as an FSA or HSA)
What is a consumer-drive health plan (CDHP)?
Health insurance policies where the insurer, or payer, and the healthcare provider have a contractual agreement with the goal of reducing healthcare costs
What is a managed care organization?
This part of Medicare offers Medicare beneficiaries Medicare Advantage plans that compete with the Original Medicare Plan
What is Part C?
The amount of out-of-pocket costs after a certain amount of money has been spent from Medicare on prescription drugs
What is the "donut-hole"?