Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Reading Chapter 3 For Unit 2’s readings, you will read Chapter 3: “An Introduction to Health

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Reading

Chapter 3

For Unit 2’s readings, you will read Chapter 3: “An Introduction to Health Insurance.” Please pay special attention to the key terms. They may just show up on your unit quiz!

Keep in mind, as you reading, you may want to make flashcards or another study tool to help you get a solid understanding of these terms.


SeminarUnit 2 Seminar

Welcome to the Unit 2 Seminar. Your instructor will lead the Discussion on these topics:

•Defining health insurance

•Managed Care

•Managed Care Organizations

•Health Insurance Terminology and Statistics

•Electronic Health Record (EHR)

•Paying the Bill With Health Insurance

•Quiz/Test Strategies for Memorizing These Terms

•Summary


AssignmentUnit 2 Assignment

In this unit, there were many new terms relating to insurance which you will want to master. For this paper, you will write a 2-3 page assignment. Pick an insurance plan, and discuss the major developments in the plan and discuss the impact on healthcare quality, access, technology, reimbursement, and so on. Also, provide your concerns about health insurance and what you think the future of health insurance should be. Create a bibliography that cites a minimum of five references according to APA format.

Submit this to your Dropbox for this unit.


Chapter 3

Introduction to Health Insurance


Health Insurance

• Health insurance provides money to pay for medically necessary care or services

• Employer-sponsored health insurance

• Government-sponsored health insurance programs

• Self-insurance


Managed Care

• Any method of organizing health care providers that gives access to high-quality, cost-effective health care

• Primary goal– Control health care cost


Managed Care

• Cost control– Reduced fees

– Fixed payment rates

– Prepaid fees

– Controlled access to specialists

– Elimination of unnecessary services


Managed Care Organizations

• Health maintenance organizations (HMOs)– Staff model

– Independent practice association

– Group model

– Network model


Managed Care Organizations

• Preferred provider organizations (PPOs)– Exclusive provider organization

• Integrated delivery systems


Health Insurance Terms

• Policy terms– Policyholder/Insured

• Purchases health insurance policy

– Coverage• Exclusions

• Preexisting conditions

• Waiver



• Reimbursement (payment) terms– Accepts assignment

– Assignment of benefits

– Benefit

– Copayment or copay

– Coinsurance

– Deductible



• Reimbursement (payment) terms– Direct-pay

• Patient pays bill

– Third-party payment• Insurance pays bill

– Fee-for-service

– Episode-of-care

– Capitation



• Coordination of benefits (COB)– More than one insurance policy

– Determine primary payer

– Bill all insurances

– Total reimbursement does not exceed total bill

Documents

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Reading Chapter 3 For Unit 2’s readings, you will read Chapter 3: “An Introduction to Health