healthcare insurers & bureaucrats positively put the U.S. Army
to shame for inventing acronyms and confusing terms. Below are most
of the common ones explained in a very simplified form. For
a more complete listing, go to http://www.healthinsurance.org
- Primary Care Physician - A "Gatekeeper" you select from
the network upon enrollment, who generally provides your routine
medical care & decides if and when you need to see a specialist.
IPA MODEL - Health Maintenance Organization - Closed plan where
you can only use listed medical providers, typically with access
to specialists controlled by your "PCP" (Primary Care
Physician). No insurance outside the plan.
"IPA" means Independent Physician Association.
STAFF MODEL - Kaiser type HMO plan where physicians are salaried
& work in the plan facility.
- Preferred Provider Organization - A plan incorporating both a
network of medical providers and an option to go outside it, but
at a reduced level of benefits. Members usually may see any doctor
in the plan without referral.
- Point of Service - A plan incorporating a closed (HMO) network
combined with an out-of-network option. Some POS plans utilize three
separate levels of benefits: HMO, PPO, and out-of-network.
OR FEE FOR SERVICE - Total freedom of choice in medical providers.
This is what we longingly look back on. It is virtually
unavailable in the current marketplace, except perhaps to those
who could probably pay their own claims anyway.
- Consolidated Omnibus Budget Reconciliation Act - The federal regs
governing eligibility & rights to continuation of coverage for
employees & dependents when group insurance terminates.
- Health Insurance Portability & Accountability Act - Federal
regs governing eligibility for the purchase of insurance to replace
lost group medical insurance.
- California state regulations applying the federal regs & revisions
- Percentage (usually) the carrier pays of your medical bill, although
some may confuse the issue by also using it to mean what you pay.
- Dollar amount you pay for a particular treatment.
FEE SCHEDULE - The dreaded scale carriers use to dictate payment
for each individual medical service when you use medical providers
outside their network. The amounts are generally set at whatever
level the insurance company wants them to be, which regularly produces
payments at some pitifully small percentage of the actual cost.
- Usual, Customary, Reasonable -- another scale setting rates of
payment for individual medical services, purported to utilize actual
historical pricing data. This scale is generally considered better
than Limited Fee Schedule, but not much.
SCHEDULE - The Medicare scale setting rates of payment for services,
generally considered in the same category as Limited Fee Schedule.
SCHEDULE - Another payment scale purported to have been produced
by a trade association.