monthly enrollment list
documentation of eligible members of a capitated plan registered with a particular PCP for a monthly
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precertification
payer preauthorization for elective hospital-based services and outpatient services
rider
document that modifies an insurance contract
carve out
part of a standard health plan that's changed under a negotiated employer-sponsored plan
utilization review organization
company hired by a payer to evaluate the appropriateness/medical necessity of hospital-based services
plan summary grid
quick reference table for health plans
stop-loss prevention
contractual guarantee against a participating providers financial loss due to an unusually large demand for high-cost services
elective surgery
surgical procedure that can be scheduled in advance
metal plans
term for the new designs for health plans created by the ACA
subcapitation
arrangement by which a capitated provider pays for an ancillary provider
repricer
vendor that processes a payer's out-of-network claims
high deductible health plan (HDHP)
an insurance plan (usually a PPO) that requires a large amount to be paid before benefits begin; part of a consumer-driven health plan
Federal Employees Health benefits program
the largest employer-sponsored health program in the US
open enrollment period
time period in which employees chose their plans in an employer-sponsored health plan
COBRA and HIPAA
portability of health insurance is governed by
ERISA
Regulates self-funded health plans
all major types of health plans
plans offered by BlueCross BlueShield Association
Emergency surgery
requires precertification (preuathorization) within a specified time after the procedure
Discounted fee-for-service
providers who pay in a PPO are paid...
a monthly enrollment list
under a capitated HMO plan, the physician practice receives this
Participation contract
document that's researched to uncover rules for private payers' definitions of insurance-related terms
group health plans
establish/regulate health plans for employees
group health plans
decide on basic plan coverage to and optional riders; eligibility requirements; premiums; deductibles
group health plan
must observe federal COBRA + HIPAA laws to ensure portability and coverage as required
PPOs
pays providers under a discounted fee-for-service structure
HMOs (and PPOs)
payment may be a salary or capitated rate > pends on business model
Indemnity
basically pays for physician's fee schedule
Consumer-driven health plans
this plan has three types of funding options for out-of-pocket expenses
Health-reimbursement account (HRA)
a type of consumer-driven health plan that's set up by an employer to give tax-advantaged funds for employer's expenses
Health savings account (HSA), Flexible savings (spending) account (FSAs)
two consumer-driven health plans that can be funded by both employee and employer on a tax-advantage basis
HSA funds
these types of funds can be rolled over, taken to another job, or used for retirement
FSA funds
this type of fund DOES NOT roll over
Anthem, United Health Group, Aetna, GIGNA Health Care, Kaiser Permanete, Humana
A small group of large insurance companies that dominate the national insurance market
BlueCross BlueShield Association (BCBS)
National organizaiton of independent companies (member plans) that cover over 100 million people [Show Less]