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What refers to the variety of policies that can be purchased to cover certain help-related services and goods?
What does it mean to be insured?
covered by a policy
Who is the individual who purchases a policy?
Who is the insurer?
health insurance company
What are benefits?
covered services (services that are reimbursed by the insurance company)
Who finances health care?
- individuals directly
What is medicare?
- federally funded
- for elderly population (65+)
- ppl with end stage renal disease
- disabled ppl who are entitled to social security
What is medicaid?
- for indigent population
- funded by state and federal govt
- states determine eligibility, reimbursments, and specific benefit level
What methodology requires payment after services have been rendered, called "fee-for-services", ind. or health insurer is at risk,and providers have little incentive to limit services?
What methodology establishes payments in advance, and the providers are paid these amounts reguardless of the costs incurred, the provider takes the risk, and contains DRGs?
What 2 things does managed care contain?
- predetermined payment schedule,
- provider network
What is the most restrictive health policy?
HMO (health maintenance organization)
What insurance provides a gatekeeper who determines everything for the patient to restrict costs?
What insurance is an open managed care model where employer negotiates lower fees in return for providing a high volume of pts?
PPO (prefered provider organization)
What insurance offers in and out of network benefits (more coverage in network), theres an annual deductible, co-payments, and insured pays difference for out of network care?
What is the evaluation of the medically necessary, appropriate, and efficient use of health care services, procedures, and facilities?
utilization review (UR)
What is a case management?
provides monitoring and coordination of txs rendered to patients to control costs and utilization
What is a consumer-driven health care plan?
combines employer contributions with increased employee choice and responsibility and increased health plan and provider accountability