Health Insurance Intro : Medical Assistants Class


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    OR REVIEW THE FOLLOWING CLASS KNOWLEDGE BLOCKS


  • The fee that an individual is required to pay for medical services, after a deductible has been paid is called

    Co-Insurance

    Rationale: Co-insurance is a portion of a health insurance plan that is often broken down by a percentage. Co-insurance is usually designated for areas of a policy that are for major, hospital related care and/or services. This can include child birth, surgeries, CT-Scan or MRI imaging, long-term hospital care, etc. Typical percentages are 10% or 20% from the individual for the related service or care, and 90% or 80% from the health insurance company to cover the remainder of the costs incurred. Co-Insurance is typically kept separate from co-payments in an insurance plan because of the costs related to the services and care from a stay in a hospital.

  • A predetermined, flat fee that an individual pays for a particular visit or health care service, in addition to what the insurance covers is called a

    Co-Payment

    Rationale: Co-Payments allow the policy-holder to obtain a prescription, visit a doctor’s office, urgent care, even an emergency department for a flat fee that does not change. Typical amounts for co-payment’s are $10, $25, $35, and $100 respectively. This flat fee is contingent upon the fact that the office being visited is within a specific network dictated by the health insurance company. This co-payment must be paid for each particular service or visit. An important note to remember is that the co-payment is for the visit itself. Depending on the services required during the visit, other charges could apply afterwards. These services could be x-rays received, labs needed for processing, sutures, minor surgeries, etc. These services are charged to the health insurance company first. The amounts remaining, if any, are then billed to the policy-holder directly.

  • The amount an individual must pay for health care expenses before insurance covers the costs is called

    Deductible

    Rationale: Deductibles are a part of most health insurance plans in one form or another. It is a fairly general rule that the higher the deductible is, the lower the premium will be. Depending on the parameters outlined in a specific policy, the deductible may apply per covered incident or per year. Generally in most health insurance plans, it is built as a per year system. At the beginning of each successive year, or amount of time outlined in a policy-holder’s specific plan, the deductible would then reset. The expectation is that the deductible will then be repaid again before receiving the plan’s benefits. Common amounts for deductibles are $500, $1000, even $2000 per policy.

  • A person or persons relying on the policy holder for the support of health coverage is called a

    Dependent

    Rationale: Dependents are the individuals registered to health insurance policies that are not the policy-holder themselves. A dependent can take advantage of all aspects of the outlined policy, but are not directly responsible for costs incurred. These costs ultimately fall to the policy-holder, since they are the primary member of the group. The policy-holder is responsible for claiming the dependents they want attached to their policy when signing up for the plan. Dependents can include the husband, wife, and children (whether natural, adopted or step children), as long as the children are unmarried.

  • A provision within a health insurance policy that eliminates coverage in the instance of certain conditions is called an

    Exclusion

    Rationale: Health insurance companies tend to install exclusions to health plans to build parameters to a policy. These limitations can be types of injuries covered, rules regarding referrals to hospitals, pre-existing conditions, and any number of other factors. Exclusions are generally an aspect of health insurance plans that are the least understood because the details tend to get lost in the fine print of a policy. In healthcare, it takes a great deal of patience to deal with situations regarding exclusions, because of the confusion they can cause to the patient.

  • A safeguard against the risk of incurring medical expenses among individuals is called

    Health Insurance

    Rationale: As healthcare and hospital services have become more technical and expensive, health insurance plans have been developed to help alleviate some of the costs of healthcare. The policy-holder is responsible for paying a premium to obtain this service. In exchange for this monthly premium, this service helps make everything from well checks to surgeries more affordable than they would be otherwise without the insurance. Without the insurance, the expectation would be that the patient would be responsible for repaying 100% of the total cost. This makes health insurance a necessity in today’s modern society.

  • Organizations that represent “pre-paid” or “capitated” insurance plans in which individuals pay a fixed monthly fee for services instead of a separate charge for each visit or service are called

    HMO's

    Rationale: HMO's, or Health Maintenance Organizations, are services provided by physicians who are under employment with, or are contractually bound to the Health Maintenance Organization. Depending on the type of the HMO, services may be provided in a central facility, or in a physician’s own office. HMO’s were created to attempt and create healthier lifestyles to save on health insurance costs in the long-term, instead of just treating the illnesses when they appear. By monitoring the lifestyle and health of the patient on a regular basis, theoretically, this would help minimize the overall need for the more expensive aspects of health insurance. This style of health care coverage is becoming more popular in modern society.

  • A health insurance program for low-income individuals who can not otherwise afford Medicare or other commercial health insurance plans is called

    Medicaid

    Rationale: Medicaid is a United States health program that individuals and families with limited income may apply for. Medicaid is the largest source of healthcare for people with limited income in the United States. The Medicaid program is funded jointly by the United States federal and state governments. However, it is run specifically by the state governments. Medicaid is only available to certain groups of people; these are U.S. citizens or legal permanent residents. And of these groups, the individuals must be low-income adults (although poverty does not necessarily qualify an individual for assistance), their children, or people with certain types of disabilities.

  • The federal health insurance program created to provide health coverage for Americans aged 65 and older is called

    Medicare

    Rationale: When an individual becomes 65 years old in the United States, a federal health insurance program called Medicare becomes available regardless of the level of income. When the individual pays taxes on their income, a part of those taxes goes to Medicare. In recent years, Medicare has become available for those who are under the age of 65 if they have a permanent disability, require continuing dialysis for a kidney transplant, or if the individual is diagnosed with Lou Gehrig’s disease, otherwise known as ALS.

  • The amount the policy-holder pays to the health plan to purchase health coverage is called a

    Premium

    Rationale: The policy-holder is the individual whose name is attached to a health insurance policy and is responsible for paying the fees attached to said policy. To receive the benefits laid out in the policy-holder’s health plan, a premium is required on a regular basis (bi-weekly, monthly, etc.). Depending on the plans offered by certain places of employment, the premium can also be paid by the policy-holder's employer, otherwise known as a sponsor.

  • The type of provider that is the health care professional responsible for monitoring an individual’s overall health care needs is called a

    Primary Care Provider

    Rationale: A primary care provider (PCP) is an individual that is your principal source for checkups and health problems in a health insurance plan. The professionals that can be the primary care providers are chosen from a list that are given to you by your insurance company. These professionals range from general practitioners or family physicians, physician assistants, to even nurse practitioners. It is the expectation that the primary care provider will be more familiar with the history of a single patient, and be able to better serve that patient and the totality of their healthcare. If required, it is the PCP that will then refer the individual to more specialized physicians for different levels of care. These referrals can be everything from cardiopulmonology to diagnostic imaging. The PCP will be able to direct you to care centers that are within your health insurance parameters as well.

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