Key Terms
What is a course of action that should be taken every time a certain situation occurs?
Policy
What is in the insurance industry, a monthly payment made to purchase insurance coverage?
Premium
What is in healthcare insurance, a limit on the total amount a subscriber must pay each year for covered services; after the subscriber meets the out-of-pocket maximum, the insurer must pay 100% of covered costs?
Out-of-pocket maximum
What is a type of health insurance in which the subscriber can chose any provider or facility for health care and receive reimbursement based on billed costs as long as the charges are considered usual, customary, and reasonable; sometimes called a fee-for-service plan?
Indemnity plan
What is a form of health insurance in which the cost of care is covered only when a person uses a particular doctor or group of doctors except in case of emergency; seeing specialists generally requires referrals from a primary care provider?
Health maintenance organization (HMO)
What is in the insurance industry, the services or items covered in an insurance policy?
Benefits
What is in the insurance industry, an amount that must be paid for covered services by the subscriber before insurance benefits are paid?
Deductible
What is a summary of coverage provided by an insurer to the subscriber and the healthcare provider after an insurance claim is made, including what portion of the charges are covered by insurance and what portion must be paid by the patient?
Explanation of benefits (EOB)
What is a system or strategy of managing health care in a way that controls costs?
Managed care
What is a managed care plan in which patients are encouraged, but not required, to see providers in a provider network established by the insurance carrier?
Preferred provider organization (PPO):
What is in the insurance industry, a request for payment of covered benefits?
Claim
What is in healthcare insurance, a set amount that must be paid by the subscriber for a covered service?
Copayment
What is a statement a document provided by an insurer to a healthcare provider summarizing a health insurance claim, including charges that have been billed, what portion are covered by insurance, and what portion must be paid by the patient?
Remittance advice (RA
What is term sometimes used to describe a primary care provider; refers to the provider’s role in managing a patient’s access to healthcare services?
Gatekeeper
What is : a type of managed care plan that requires the patient to see network providers for all health services?
Exclusive provider organization
What is in health insurance, an individual who receives insurance benefits due to a relationship to the subscriber (e.g., a child or spouse)?
Dependent
What is in healthcare insurance, a percentage of charges that must be paid by the subscriber for a covered service?
Coinsurance
What is a standard fee for a treatment, service, or supply set by an insurer; providers contracted with an insurer are obliged to accept this amount as payment?
Allowable amount
What is a form of managed care payment in which a provider receives a flat fee for each patient each month rather than receiving payment for each service provided.
Capitation fee
What is a type of managed care plan that requires the patient to choose a primary care provider and see specialists in the provider network with a referral; patients may see providers outside the network but will pay more to do so?
Point-of-service plan
What is In health care, the person who is financially responsible to pay a medical bill?
Guarantor
What is a federal law enacted in 2010 with the goals of making insurance affordable to more people, expanding Medicaid coverage, and supporting care practices that improve patient health and lower costs?
Patient Protection and Affordable Care Act (ACA)
What is something added to an insurance policy that changes the terms of the policy, for example to add specific additional coverage?
Rider
What is a federal health insurance program for people who are 65 or older, have certain disabilities or permanent kidney failure, or are ill and cannot work.
Medicare
What is a private insurer contracted to manage Medicare claims in a specific geographical region.
Medicare Administrative Contractors (MACs)