Managed Care Plans
An organization that has clients pay a monthly fee for service at in network facilities.
Require the selection of a Primary Care Physician (PCP) who acts as a gatekeeper
HMO
Contributory Plan
Employers fund and pay claims directly
Self-Funded Plans
Requires Pregnancy be treated as any other health condition
Pregnancy Discrimination Act
Someone you have to go through to get referrals to specialists
Gatekeeper
Plans focus on controlling healthcare costs through networks and utilization management
Managed Care Plans like HMOs PPOs and POSs
Non-Contributory Plans
Individual policies issued to association/professional society members
Franchise Plan
Ensures portability between healthcare plans and privacy protection for health information
HIPAA
Reimburses insureds for healthcare costs after services are received
Traditional Health Insurance (also known as indemnity plan or commercial plan)
prospective, concurrent, retrospective overview of patient care and treatments
Utilization review
A group that exists for a purpose other than to get insruance.
Natural Group or Eligible Group
Two or more unrelated employers providing benefits
MEWA
Requires continuation coverage after qualifying events
COBRA
Fixed amount payed before insurance kicks in
Copay
Staff Model, Group Model, Network Model, and Independent Practice Organization
Four main types of HMO structures
A method of underwriting used for large groups (51+ employees) based on the group's actual claims history
Experience Rating
Fully insured MEWAs established by third parties
METs
Small Group Regulations
Eligibility to join a group or coverage for illness
Probationary Period
an organization that offers a discount for in-network services
PPO
A method of underwriting used for small groups (2-50 employees) based on the claims experience of the community.
Community Rating
I couldnt think of anything soooo
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Laws regulating group insurance
Erisa
Death, disability, or divorce
Qualifying Events