Chapter 9-Private Payers-Blue Cross & Blue Shield
Key Words
Administrative Services Only ASO-Contract under which an insurance carrier works as a Third Party
Administrator for a self-funded health plan
Blue Card-Provides benefits for plan members who are away from their local area
Blue Cross and Blue Shield-National organization
Cafeteria Plan-Choose from a wide variety of options for benefits
Capitation Plan-Monthly enrollment list of policyholders, eligible members, PCP, no pre-cert required
Carve Out-A part of a standard health plan that is changed under a negotiated Employee Sponsored Health
Plan, also refers to subcontracting coverage of benefits
Consumer Driven or Directed Health Plan CDHP-Empowers consumers to manage their use of healthcare
services and products. HRA, HAS, FSA, usually a PPO
Consolidated Omnibus Budget Reconciliation Act COBRA-When leaving a job the right to continue health
coverage under employers plan for a limited amount of time
Credentialing-Done by health plans as they select doctors and hospital to join their networks
Creditable Coverage-Previous insurance coverage that must be counted by a new employer in enrolling into
a new employee health plan
Discounted Fee-for-Service-Payment structure PPO’s usually offer in their contract with providers
Elective Surgery-Performed on a scheduled basis. Usually require a preauthorization
Episode-of-Care-Pays doctor a flat fee to handle all services of a particular type of contract
Employee Retirement Income Security Act of 1974 ERISA-Run by the Department of Labor and Pension and
Welfare Benefits Administration, protects companies which set up employee health and pension plans
Family Deductible-Type of deductible must be met by one or more enrollees on a contract within a family
Federal Employees Health Benefits Program-FEHBP-Largest employer sponsored health program. Covers
federal employees, retirees and their families
Flexible Blue-CDHP
Formulary-List of approved drugs, have smaller copays
Flexible Savings Account-FSA-Pretax money put into a fund to pay for medical expenses. Funded by
Employee
Group Health Plan-Employer buys from insurance company. Governed by HIPAA
High Deductible Health Plan-HDHP
Health Reimbursement Account HRA-Reimbursement plan set p and funded by employer
Health Savings Account HSA-Set up by individual
Home Plan-Blue Cross refers to community where subscriber has his coverage
Host Plan-Out of area from home plan-Blue Cross
Individual Health Plan IHP-Individual policy-expensive
Independent Practice Association IPA-Type of HMO that is made up of physicians
Individual Deductible-Type of deductible must be met for each enrollee
Late Enrollee-An individual when enrolls in a plan at a time other than the earliest possible enroll date
Managed Care Contract-Must be evaluated by practices from a financial standpoint
Monthly Enrollment List-Contains those eligible members of capitated plan who are registered with a
particular PCP
Open Enrollment Period-Time in which employee can choose a plan for coming benefits period
Participation Contract-Providers decide whether to participate in a managed care plan. Based on types of
patients served and financial arrangements
Pay-for-Performance P4P-Financial incentive program improvement in providers work
Plan Summary Grid-Contains payer’s names, plans, patient financial responsibility, co-pays, deductibles,
referrals, preauthorization requirements, covered and non-covered services, bill information and
participating labs
Pharmacy Benefit Manager PBM-Arrange for prescription drug benefits-inexpensive
Repricer-Company that works for the plan and sets the discount for each out of network providers
Rider-Document that modifies insurance contract “options”, added to insurance plan
Self Funded Plan-Regulated by ERISA
Silent PPO-Extends contractural discounts to plans with which the practice does not have participation
discounts (network-sharing arrangements)
Stop-Loss-Provisions intended to protect providers-provisions are included in capitation, rather than
indemnity participation. Protect providers against extreme financial loss
Subcapitation-When MCO hires another organization to provide certain medical services on a capitated bases
Summary Plan Description SPD-Describes benefits and legal rights
Third Party Claims Administrator TPA-Provides administrative services for medical insurance plans
Tiered Network-Encourage patient’s too see plans most cost effective highest quality provider
Utilization Review Organization URO-Hired by payers to review the appropriateness planned medical services
Waiting Period-Amount of time that must pass before an employee can enroll in a health plan. Time between
the date of hire and date insurance becomes effective