Insurance and Plan Types
This type of insurance is provided by private companies, often through employers
What is Commercial Insurance?
Digital records of a patient's medical history are contained in this
What are EHRs or EMRs? (Electronic Health Records, or Electronic Medical Records)
Also known as Obamacare, this law aimed to increase health insurance accessibility
What is the Affordable Care Act (ACA)?
The percentage of premium dollars spent on medical expenses versus administrative costs is referred to by this term
What is MLR (Medical Loss Ratio)?
This team helps a health plan's members navigate the healthcare system and coordinate care.
What is the Care Management team?
This government program provides health coverage to low-income individuals and families
What is Medicaid?
Members of this profession help individuals and employers select health insurance plans
Who are Health Plan Brokers?
This federal law sets standards for health information privacy
What is HIPAA? (The Health Insurance Portability and Accountability Act)
PMPM is a key revenue metric that translates to this phrase
What is "per member per month"?
This key industry trend is helping more health plan leaders gain bargaining leverage, branding power and economies of scale.
What is consolidation?
This federal health insurance program for those 65+ offers coverage through Part A and Part B
What is Original Medicare?
This association of health plans was once the province of non-profit companies, but has evolved to include for-profit plans.
What is the Blue Cross Blue Shield Association?
This healthcare celebrity will soon be the head of CMS, likely unlocking new growth for Medicare Advantage plans.
Who is Dr. Oz?
CMS uses this rating system to gauge health plan quality, using elements such as member satisfaction.
What are STAR ratings?
Through this process, health plans evaluate the necessity and appropriateness of medical procedures and services
What is Utilization Management?
This type of Medicare plan allows participants to receive benefits through private insurance companies
What is Medicare Advantage?
This care-delivery technology changed how patients received care during Covid, and it remains popular enough that health plans often still cover it.
What is telehealth?
This healthcare delivery model reimburses providers based on the patients' health outcomes
What is Value-based care?
For Medicare Advantage and similar plans, insurers are reimbursed more - or less - per patient depending on this health-related score
What is Risk Adjustment?
A health plan's care management team is comparatively expensive to maintain because it relies on these types of medical professionals
What are nurses?
This plan type offers more provider flexibility but typically has higher premiums
What are PPOs (Preferred Provider Organizations)?
New CMS rules mandating quicker Utilization Management decisions require plans to render decisions within this period of time
What is 3 days (urgent) or 7 days (non-urgent)?
The opposite of the value-based care model is one in which doctors bill for each service provided. This model is known by this term.
Fee for Service
This standard set of measures is used by the industry to evaluate health plan performance
What are HEDIS measures?
This process is how clinicians obtain a health plan's approval before they can perform certain medical procedures
What is Prior Authorization?