AHIP PHIAS flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Usual, Customary, and Reasonable

A reimbursement benchmark used by indemnity plans: the amount typically charged by providers in a geographic area for a given service. Charges above it may be the member's responsibility.

Primary Care Gatekeeper

An HMO feature in which the primary care physician coordinates care and authorizes specialist referrals. Without a referral, non-emergency specialist care may not be covered.

PPO Network Tiers

PPO plans pay a higher share for in-network providers and a lower share for out-of-network providers, often with a separate deductible. No referral is required to see specialists.

Exclusive Provider Organization

An EPO covers only in-network providers except for emergencies. It usually requires no primary care gatekeeper or referrals and offers no out-of-network benefits.

Out-of-Pocket Maximum

The annual limit on member cost sharing for covered essential benefits. Premiums, balance billing, and non-covered services typically do not count toward reaching it.

Point of Service Plan

A hybrid plan allowing members to choose in-network care managed by a primary care physician or out-of-network care with a deductible and higher coinsurance.

Prior Authorization

A managed care utilization control requiring the plan to approve certain services, drugs, or procedures before they are delivered, based on medical necessity criteria.

Balancing Billing

A provider's charge to the patient for the difference between the billed amount and the plan's allowed amount. It can occur with out-of-network care where the plan limits payment.

Medicare Part A

Hospital insurance covering inpatient stays, skilled nursing facility care after a qualifying stay, hospice, and some home health. It uses benefit periods with deductibles and daily coinsurance.

Medicare Part B

Medical insurance covering physician, outpatient, and preventive services. After the annual deductible, it generally pays 80% of approved charges, leaving 20% to the beneficiary.

Medicare Advantage Plan

A private plan providing all Part A and Part B benefits, often including Part D and extra benefits, using networks, prior authorization, and copayments in place of original Medicare.

Medigap Standardization

Most states require Medicare Supplement plans to follow standardized benefit designs, so plans with the same letter offer identical core benefits across insurers.

Annual Election Period

The Medicare window from October 15 to December 7 when beneficiaries may change Part D or Medicare Advantage elections, with coverage changes effective January 1.

Medicare Secondary Payer

Coordination rules determining whether Medicare or another plan pays first. Employer plans pay first for active workers at employers with 20 or more employees.

Part D Coverage Gap

A phase of the Part D benefit after initial coverage in which enrollees pay a larger share of drug costs, with manufacturer discounts applied, until catastrophic coverage begins.

Observation Versus Inpatient

A hospital status distinction under the 48-hour notice rule. Observation status can disqualify a Medicare Advantage enrollee from skilled nursing facility coverage.

Health Reimbursement Arrangement

An employer-funded account that reimburses employees for qualified medical expenses. Only the employer contributes, unused funds may roll over, and the employer sets the rules.

Health Savings Account

A tax-advantaged account available with a qualifying high-deductible health plan. Contributions are pretax, growth and qualified withdrawals are tax-free, and funds are portable.

Flexible Spending Arrangement

An employer-sponsored salary-reduction account for medical or dependent care expenses. It is generally use-it-or-lose-it, though carryover or grace periods may apply.

Qualifying High-Deductible Plan

A health plan meeting IRS minimum deductible and maximum out-of-pocket limits required for HSA eligibility. Preventive care may be covered before the deductible is met.

Hospital Indemnity Policy

A supplemental fixed-benefit policy paying a set daily or per-stay amount during a covered hospital confinement. Benefits are paid regardless of other coverage.

Critical Illness Insurance

Supplemental coverage paying a lump sum upon first diagnosis of a covered condition such as cancer, heart attack, or stroke. Benefits are not coordinated with major medical.

COBRA Continuation

A federal right for qualified beneficiaries to continue group coverage after a qualifying event, generally up to 18 months, by paying the full premium plus an administrative fee.

Short-Term Medical Plan

A non-ACA-compliant policy with limited duration and benefits. It may exclude pre-existing conditions and is not required to cover essential health benefits.

Own-Occupation Definition

A disability policy standard that pays benefits when the insured cannot perform the duties of their own occupation, even if they could work in another field.

Any-Occupation Definition

A stricter disability standard that pays only when the insured cannot perform any occupation for which they are reasonably suited by education, training, or experience.

Elimination Period

The waiting period between the onset of disability and the start of benefit payments. A longer elimination period reduces the policy premium.

Activities of Daily Living

Basic self-care tasks such as bathing, dressing, eating, toileting, and transferring. Inability to perform a set number commonly triggers long-term care benefits.

Long-Term Care Partnership

A state program linking qualifying long-term care policies to Medicaid. Policyholders who exhaust benefits may receive protection of assets when applying for Medicaid.

Worksite Voluntary Benefits

Employee-paid products such as disability, accident, critical illness, and life coverage offered through an employer, often with payroll deduction and simplified or guaranteed-issue underwriting.

Disability Benefit Offset

A provision reducing disability benefits by other income the insured receives, such as Social Security or workers' compensation, to limit total income replacement.

Taxation of Disability Benefits

Disability benefits are taxable to the recipient when the employer paid the premiums. If the employee paid premiums with after-tax dollars, benefits are generally tax-free.