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The Medical Assistant > Ch 14: Basics of Health Insurance > Flashcards

Ch 14: Basics of Health Insurance Flashcards

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USMLE® Step 1 flashcards
1
Q

A recipient of health insurance benefits

A

Beneficiary

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2
Q

A contract between the health insurance plan and the provider 4 which the health insurance plan will pay an agreed-upon monthly fee per patient and the provider agrees 2 provide medical services on a regular basis

A

Capitation

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3
Q

A document sent by the insurance company 2 the provider and the patient explaining the allowed charge amount, the amount reimbursed 4 services and the patient’s financial responsibilities

A

Explanation of benefits

EOB

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4
Q

A reimbursement model in which the health plan pays the provider’s fee 4 every health insurance claim

A

Fee-4-service

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5
Q

The primary care provider, who can approve or deny when the patient seeks additional care via a referral 2 a specialist or further medical tests

A

Gatekeeper

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6
Q

Health insurance programs that r sponsored by the government and offer coverage 4 the elderly, military and indigent

  • patients must meet the application requirements
A

Government-sponsored health insurance

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7
Q

An online service provided by various insurance companies 4 providers 2 look up patient insurance benefits, eligibility, claims status and explanation of benefits

A

Online provider insurance Web portal

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8
Q

Health insurance companies that operate 4 profit and use managed care plans 2 reduce the cost of healthcare

A

Privately sponsored health insurance

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9
Q

Low-income Medicare patients who qualify 4 Medicaid 4 their secondary insurance

A

Qualified Medicare beneficiaries

QMB

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10
Q

The intermediary and administrator who coordinates patients and providers and processes claims 4 self funded plans

A

3rd-party administrator

TPA

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11
Q

The person who is the signer on the health insurance policy

A

Subscriber

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12
Q

A process of managing healthcare costs by influencing patient care decision making by case-by-case assessments of the appropriateness of care

A

Utilization management

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13
Q

The amount of time that a patient waits 4 disability insurance 2 pay after the date of the injury

A

Waiting period

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14
Q

Health insurance plans that cover health services and procedures that r necessary 2 improve the patients current health condition

A

Medically necessary

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15
Q

Procedures that r not deemed medically necessary or needed 2 improve the patients current health

Ex. Facelifts

A

Elective procedures

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16
Q

Care which includes services provided to prevent certain illnesses

A

Preventive care

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17
Q

A privately sponsored health insurance plan purchased by an employer 4 a group of employees

A

Group policy

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18
Q
  • offsets cost of medical care
  • Defined as a contract 4 protection against financial losses resulting from illness and injury
  • provides a payment of monetary benefits 4 covered sickness or injury, dependent on purchased policy
A

Purpose of health insurance

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19
Q

-to obtain health insurance, patients must apply either through their employer or privately

  • 2 types of health insurance plans in the US:
    - privately-sponsored health insurance plans
    - government-sponsored health insurance plans
A

Contract w/ patients

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20
Q
  • A type of health insurance plan

- employers usually sponsor A percentage of the monthly

A

Employer-sponsored group policies

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21
Q

A type of health insurance plan

-Individuals go out and purchase their own plan

A

Individual health insurance plans

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22
Q

A type of health insurance plan

  • Passed in 2010
  • increases the quality, availability, and affordability of private and public health insurance for more than 44 million unsure of Americans.

-Involves:
-Ambulatory patient services
-emergency services
-hospitalization
-maternity and newborn care
-mental health and substance abuse disorder services including
behavior health services
-prescription drugs
-rehabilitation and health habilitative services and devices
-Laboratory services
-preventative services and wellness services; chronic disease
management, pediatric services, including oral and vision care

A

The Affordable Care Act/Obamacare

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23
Q

A type of health insurance plan benefit

  • Covers cost of all or part of the hospital room and board; and specific hospital services
  • pays maximum amount per day and a maximum number of days
A

Hospitalization

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24
Q

A type of health insurance plan benefit

  • Covers any surgical procedure, including but not limited to incision or excision; aspiration, standing; reduction of fractures
  • his surgeons fees and assistant surgeon fees
A

Surgical

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25
Q

A type of health insurance plan benefit

  • Covers outpatient and physician office procedures and services
  • pays physicians fees; diagnostic, radiologic, laboratory, and pathology fees
A

Basic medical

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26
Q

A type of health insurance plan benefit

  • Covers catastrophic or prolonged illness or injury
  • takes over when basic medical hospitalization and surgical benefit and
A

Major medical

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27
Q

A type of health insurance plan benefit

  • covers accident or illness resulting in and in the billet T for patient to work; can be paid whether work related or not
  • pays cash benefits in Lou of salary while patient is an able to earn an income
A

Disability

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28
Q

A type of health insurance plan benefit

Covers preventative care; treatment and repair of teeth and gums

-typically pays 100% for preventative care and 50% for repair and treatment

A

Dental care

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29
Q

A type of health insurance plan benefit

  • Covers our examinations and glasses or contacts
  • page is set benefit amount, depending on care policy for examination and glasses
A

Vision care

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30
Q

A type of health insurance plan benefit

  • Covers the deductible and coinsurance amount and paid by Medicare
  • his deductible and coinsurance amount and paid by Medicare
A

Medicare supplement

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31
Q

A type of health insurance plan benefit

  • Covers loss of life
  • usually pays a lump sum upon the life insurance benefit
A

Life insurance

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32
Q

A type of health insurance plan benefit

  • Covers long-term skilled nursing or rehabilitation care
  • pays set amount is determined by policy benefits
A

Long-term care

33
Q

A type of health insurance plan benefit

-coverage pays cost of all or part of:
-hospital room and board
-Policy is usually set maximum amount payable per day and
maximum days of care

A

Hospitalization

34
Q

A type of health insurance plan benefit

  • coverage pays all or part of a surgeons fees
    - Some plans also paid for an assistant surgeon
  • coverage includes any incision or exigent, removal of foreign bodies Carme, aspiration, suturing, and reduction of fractures
  • insurer frequently provides system subscriber with surgical fee schedule that is amounts insurer will pay for commonly performed procedures
A

Surgical

35
Q

A type of health insurance plan benefit

  • Pay all or part of his physicians fee for non-surgical services, including a hospital, home, and office visit.
  • Patient usually pays deductible and a copayment or coinsurance payment each time
  • may include a provision for diagnostic laboratory, radiology, and pathology all fees
A

Basic medical

36
Q

A type of health insurance plan benefit

  • Provides protection against large medical bills resulting from catastrophic or prolonged illness is
  • covers most serious medical expenses up to a maximum amount, usually after a deductible and coinsurance have been met
A

Major medical

37
Q

A type of health insurance plan benefit

  • Insurance beneficiaries earned income against risk that a disability will make working uncomfortable, painful, or impossible
  • encompasses paid sick leave and short term and long term disability benefits
  • Many policies do not start payments until after a specified number of days or until a certain number of sick leave days have been used
  • payment is made directly to individual, intended to replace lost income
A

Disability protection

38
Q

A type of health insurance plan benefit

-May include reimbursement for all or a percentage of cost for refraction, lenses, and frames

A

Vision care

39
Q

A type of health insurance plan benefit

-A supplemental health insurance policy to help defray medical costs not covered or only partially covered by Medicare

: Medicare supplements that cover Medicare recipients out-of-pocket expenses called Medigap policy’s

A

Medicare supplement

40
Q

A type of health insurance plan benefit

  • Covers losses to a third-party that caused by the insured
  • Types include automobile business and homeowners policies
A

Liability insurance

41
Q

A type of health insurance plan benefit

  • provide payment of a specified amount on the insured’s death
  • sometimes provides the monthly cash benefits if policyholder it becomes permanently and totally disabled
  • Sometimes proceeds from life insurance are used to meet expenses of insured person’s last illness
A

Life insurance

42
Q

A type of health insurance plan benefit

  • Covers a broad range of maintenance and health services for chronically ill, disabled, or develop mentally delayed individuals
  • services may be provided on an inpatient basis, on an outpatient basis, or at home
A

Long-term care insurance

43
Q

A type of health insurance plan benefit

  • Patients covered by an employer sponsored group health insurance plan typically share the cost for the monthly payment
  • Individual health insurance market places have monthly fees
  • indigent, elderly, federally employed employees or military patients who seek healthcare from the government have little or no monthly fees
A

Premiums

44
Q

A type of health insurance plan benefit

Proof of health insurance coverage

Includes:

  • health insurance company
  • health plan name
  • health plan type
  • patients name
  • subscriber ID
  • Health plan contact phone numbers
A

Health insurance identification card

45
Q

Healthcare facilities that are Contracted in the patient’s health insurance plan, including:

  • medical offices
  • urgent care centers
  • hospitals
A

In network healthcare

46
Q

Healthcare facilities that are Not covered by the patient’s insurance plan.

A

Out of network

47
Q

Providers that are contracted with the insurance plan and have agreed to except the contract fee schedule

Healthcare providers can apply for this through a process called credentialing

A

Participating providers

PAR’s

48
Q

A process of confirming the healthcare providers qualifications, including the healthcare providers license to practice medicine, affiliated organizations, and his or her education and professional background

A

Credentialing

49
Q

The maximum amount that third-party payers will pay for a procedure or service.

A

Allowable charge

50
Q

Two names for traditional healthcare insurance plans that pay for all or a share of the cost of covered services, regardless of which provider, hospital or other licensed healthcare provider is used

Referred to as a traditional plan because it preceded the advent of managed-care organizations (HMO‘s), Preferred provider organization ( PPO’s)and point of service (POS) plans.

A

Indemnity plans

      -or-

Major medical

51
Q

A health insurance plan where the health insurance company agrees to pay for certain surgical or medical services without additional cost to the person insured.

No set fee schedules

Premiums are higher but reimbursements are larger

A

Service benefit plans

52
Q

America’s oldest and largest system of privately sponsored insurers

Created in 1900 from the lumber and mining camps of the Pacific Northwest and set the president for monthly prepaid healthcare

Providers agree to bill the patient only for the deductible and co-pay /co-insurance amounts that are based on their allowed rates, and the full charge for any uncovered services.

A

Blue Cross\Blue Shield

53
Q

A type of healthcare organization

This organization contracts with various healthcare providers and medical facilities at a reduced payment schedule for their insurance members.

Patient care is coordinated through a diverse network providers and hospitals.

Different types include:

  • HMO’s
  • IPA
  • staff model
  • group model
  • PPO
  • EPO
A

Managed-care organizations

MCO’s

54
Q

Passed in 1973 which provided for federal aid to health insurance pre-payment plans that Matt certain criteria, this legislation brought about a rapid growth in HMOs

A

Health Maintenance Organization Act

55
Q

A type of MCO

They are state license health plans that are regulated by law that require them to include preventive care, such as routine physical examinations and other services, as part of their benefits package

Their goal is to reduce the cost of healthcare

Benefits include:

  • lowest monthly premiums with lower patient financial responsibility
  • Must select PCP
A

Health Maintenance Organization

56
Q

A general practitioner who acts as the gatekeeper two more specialized care

A

Primary care Physician

PCP

57
Q

A type of HMO

A group of providers other healthcare professionals under contract to provide services to members of different HMOs

A general or family practice provider or provider group that practices independently and they contract with several IPAs

Usually has a fixed fee per patient and can be structured as either captation or fee-for-service fee schedule

A

Independent Physician Association

IPA

58
Q

A type of HMO

Hires salary to healthcare providers and contracts with providers to create and own the network

Medical care is authorized by the PCP

No captation or fee-for-service payment structure but has contract salary amounts

A

Staff Model

59
Q

A type of HMO

They contract with a multi specialty medical group to deliver care to its members and usually practice together in one facility

Does not require a PCP and uses captation or fee-for-service repayment

A

Group Model

60
Q

A type of MCO (not a HMO)

A managed care network that contracts with a group of providers; the providers agree on a predetermined list of charges for all services, including those for both normal and complex procedures.

The patients financial responsibilities represent on average 20% to 25% of the allowed charge, however, this depends on the patient’s health insurance benefits.

They furnish their subscribers with a list of participating providers in healthcare facilities from which they can access in network health care at reduced rates

A

Preferred Provider Organization

PPO

61
Q

A type of MCO (not a HMO)

Combines features of an HMO and a PPO patients will not be covered for services outside it does need to network of providers (unless there is an emergency) but may not need to obtain a referral for specialized care

Members are not required to choose a PCP

A

Exclusive Provider Organization

EPO

62
Q

Patients must obtain this in order to see some1 other than 1’s PCP

3 types:

  • regular
  • urgent
  • STAT
A

Referrals

63
Q

A type of referral

Usually takes 3 to 10 working days for review and approval. This type of referral is used when the provider believes that the patient must see a specialist to continue treatment.

A

Regular referral

64
Q

A type of referral

Usually takes about 24 hours for approval. This type of referral is used when an urgent but not life-threatening situation occurs.

A

Urgent referral

65
Q

A type of referral

Can be approved online when it is submitted to the utilization review department through the providers web portal.

It is used during emergency situations as indicated by the provider.

A

STAT referral

66
Q

Requires pre-authorization in order to proceed with the procedure

A

Surgical procedures

67
Q

Provides the following information:

  • authorization code
  • date on which the referral request was received by the utilization review department
  • the date on which the referral was approved and it’s expiration date
  • The exact time Authorization is valid
  • authorized diagnosis and procedural codes
  • name, address, and telephone number of the contracted specialist was the authorize services will be provided
  • the comment section
  • specified number of authorized visits to the specialist
  • maybe issued for evaluation only, orEvaluation and treatment plan or evaluation and biopsy or evaluation and one injection and so on
A

Pre-authorization forms

68
Q

They review individual cases to make certain that medical care services are medically necessary to ensure that providers are using the resources efficiently

A

Utilization review committee

69
Q

A type of government sponsored plan

Established in 1966 and is the worlds largest insurance program

Provides healthcare coverage for individuals aged 65 and older, the disabled, and patients diagnosed with an stage renal disease (ESRD)

A

Medicare

70
Q

A type of government sponsored plan

Part of Tittle XVIII of the Social Security Act

Is known as the Centers for Medicare and Medicaid services (CMS) and A division of the Department of Health and Human Services (DHHS) and laws are Enacted by Congress to regulate the program.

This plan is divided into four parts: Part A - Part D

Medigap is a optional policy That pays the deductible and the 20% co-pay meant for those who choose to pay for the additional coverage

A

Medicare

71
Q

A type of government sponsored plan

Tittle XIX of Public Law 89 to 97, under the Social Security Amendments of 1965

Created to provide health care for the poor and needy but qualifications can very state to state. Their fee schedule is the lowest of all insurance companies and is not always in the medical offices financial interest to accept these patients

Qualified patients include:

  • poor and medically needy
  • recipients of AFDC (needto Families with Dependent Children)
  • receiving SSI
  • certain types of state or federal aid
  • QMB’s (qualified cat Medicare Beneficiaries)
  • receiving long term care
A

Medicaid

72
Q

A state-funded program for children whose family income is above the Medicaid qualifying income limits.

Premiums are typically 5% of the family monthly income and covers routine check ups, immunizations, doctor visits, prescriptions, dental care, vision care, inpatient and outpatient hospital care, laboratory tests, x-rays, and emergency services.

A

Children’s Health Insurance Program

CHIP

73
Q

A part of the Medicare plan

Covers:

  • inpatient hospital care
  • skilled nursing facilities
  • home health care
  • hospice services

Monthly premium: $0

Deductible: $1288 deductible for each benefit period

A

Part A

74
Q

A part of the Medicare plan

Covers:

  • outpatient hospital care
  • durable medical equipment
  • providers services
  • other medical services

Monthly premium: $104.90

Deductible: $166 +20% coinsurance for all medical services

A

Part B

75
Q

A part of the Medicare plan

Covers:Expanded inpatient hospital and outpatient hospital care benefits

Monthly premium: varies by plan

The duct a bowl: varies by plan

A

Part C

76
Q

A part of the Medicare plan

Covers: prescription drugs

Monthly premium: varies by income

Deductible: varies by plan

A

Part D

77
Q

A type of government sponsored plan that serves all military personnel

Congress passed the Dependents medical Care Act of 1956 and the Military Medical Benefits Amendments of 1966. This allowed the Secretary of Defense to contract with civilian healthcare providers. This became known as the Civilian Health and Medical Program of the Uniform Services (CHAMPUS)

A

TRICARE

78
Q

A type of government sponsored plan in all 50 states

And insurance plan for individuals who are injured on the job either by accident or an acquired illness.

Benefits include:

  • medical care and rehabilitation benefits
  • weekly income replacement benefits for temporarily disability
  • permanent disability settlements
  • survivor benefits when applicable

Paid for by employers; Patients receive no bills.

A

Workers Compensation

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