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15 Cards in this Set
- Front
- Back
characteristics of an HMO?
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-comprehensive health care
-physician gatekeepers; primary care physician -limited referral to outside specialties -low out of pocket costs -may cover more services |
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characteristics of a prefferred provider organization (PPO)?
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-economic incentives to use certain physicians, labs, and hospitals
-dont need primary care physicians |
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fee for service
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-physician paid for each service provided
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capitation
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-per member per month amount prepaid to physician (paid on fixed time schedule)
-amount based on gender/age |
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what is medicare and who do they cover?
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-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 |
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what is part A of medicare?
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-hospital insurance
-covers inpatient hospital, skilled nursing facility, hospice and some health care |
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what is part B of medicare?
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-medical insurance
-covers physician services, outpatient hospital, preventive services, certain home services, and DME |
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what is part C of medicare?
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-medicare advantage
-private managed care plan |
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what is part D of medicare?
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-prescription drug benefit
-private companies approved by medicare -monthly premium -$250 deductible per year |
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what is the defn of allowed physician payment?
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-maximum amount to be collected for medical service from all sources of payment (medicare-approved amount)
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coinsurance
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-amount patient is required to pay for services after any deductible is paid
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copayment
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-amount patient pays for each medical service
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medigap
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-costs patient must pay (deductibles, copayments, and coinsurance) = gaps in original medicare coverage
-medical supplement insurance provided by a private company |
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who is covered by medicaid?
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-State and federally funded health program; state administered
-Entitlement program those who meet eligibility requirements are guaranteed coverage -Low income and medically vulnerable people |
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who qualifies for medicaid?
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-children (<19)
-pregnant women -families with children under 18 -adults over 65 -individualls with diabilities or who are legally blind |