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15 Cards in this Set

  • Front
  • Back
characteristics of an HMO?
-comprehensive health care
-physician gatekeepers; primary care physician
-limited referral to outside specialties
-low out of pocket costs
-may cover more services
characteristics of a prefferred provider organization (PPO)?
-economic incentives to use certain physicians, labs, and hospitals
-dont need primary care physicians
fee for service
-physician paid for each service provided
-per member per month amount prepaid to physician (paid on fixed time schedule)
-amount based on gender/age
what is medicare and who do they cover?
-federal health insurance program
-people >65
-younger than 65 with certain disabilities
-all ages with end stage renal disease
-covers people without regard to income or medical history
what is part A of medicare?
-hospital insurance
-covers inpatient hospital, skilled nursing facility, hospice and some health care
what is part B of medicare?
-medical insurance
-covers physician services, outpatient hospital, preventive services, certain home services, and DME
what is part C of medicare?
-medicare advantage
-private managed care plan
what is part D of medicare?
-prescription drug benefit
-private companies approved by medicare
-monthly premium
-$250 deductible per year
what is the defn of allowed physician payment?
-maximum amount to be collected for medical service from all sources of payment (medicare-approved amount)
-amount patient is required to pay for services after any deductible is paid
-amount patient pays for each medical service
-costs patient must pay (deductibles, copayments, and coinsurance) = gaps in original medicare coverage
-medical supplement insurance provided by a private company
who is covered by medicaid?
-State and federally funded health program; state administered
-Entitlement program those who meet eligibility requirements are guaranteed coverage
-Low income and medically vulnerable people
who qualifies for medicaid?
-children (<19)
-pregnant women
-families with children under 18
-adults over 65
-individualls with diabilities or who are legally blind