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otázka		odpověď
staff model HMO začněte se učit		Physicians are employees of the HMO and paid a salary
Network model začněte se učit		the HMO contracts with at least two groups medical practices described as in network 2
independent practice Association začněte se učit		Marcus the health plan Physicians contract with the IPA to treat members of HMO
preferred provider organization PPO začněte se učit		a delivery Network that manages and negotiate contracts on behalf of the providers
Health maintenance organizations HMO začněte se učit		prepaid health plan
actuary začněte se učit		a professional who calculates insurance and annuity risks premiums and dividends
exclusive provider organizations EPO začněte se učit		delivery Network inwhich patients must use the services of those provided
copay začněte se učit		the out-of-pocket expense you pay the doctor
deductible začněte se učit		the amount of money the insurer paid before the insurance company will pay
subscriber začněte se učit		Blue Cross Blue Shield known as subscribers rather than policyholders
premium začněte se učit		the price paid by the insured for insurance coverage
capitation začněte se učit		payment method under which each patient is entitled to receive a set dollar amount of services in each time period
Usual fee začněte se učit		determined by whether a provider normally charges for that service
customary fee začněte se učit		based on fee charged buy similar providers within geographic area
reasonable fee začněte se učit		any special circumstance of this accident
cobra. consolidated Omnibus budget reconciliation Act začněte se učit		provides that the employee may continue to be insured through employer plan even after being fired. employee picks up total cost
ERISA. Employee Retirement income Security Act začněte se učit		Federal legislation the mandates how employer funded benefit plans must be in administered
coordination of benefits začněte se učit		if a service is covered under more than one policy then the insurance companies determine who pays
third-party payer začněte se učit		insurance company, government, and Managed Care Organization
Prepaid Plan začněte se učit		all types of health plans in which fixed payments are made before services are rendered
pre-authorization začněte se učit		Insurance requires that certain procedures be authorized by the insurer before they are performed. failure will result in denial of claim
gatekeeping začněte se učit		process of restricting access to services
what is the uninsured statistic začněte se učit		45.7 million people or 17% without insurance
Indemnity insurance začněte se učit		one-party is exempt from incurred liabilities by the other party
self-insured začněte se učit		employer pays for Employees Healthcare
third-party admin začněte se učit		companies that manages the paperwork for an employer who establishes a self insured plan
Managed Care začněte se učit		describes the combination of payment for Healthcare and delivery of services into one system
what did Blue Cross Blue Shield originally cover začněte se učit		they prepaid Baylor University 2 hospitalized for 21 days. a group of teachers
what does a self-insuring employer do začněte se učit		the employer pays for Employees Healthcare
what percentage of Americans are covered by some type of insurance začněte se učit		78%

Chapter 3

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