Ch.2 Health

Question 1

Blue Cross and Blue Shield

Answer 1

(BCBS) is a non profit federation of health insurance organizations in the U.S. that provides a range of health insurance plans, including individual, family, and employer-sponsored coverage. They offer various health benefits and services, including medical, dental, and vision care, through a network of doctors and hospitals. BCBS is known for its extensive network and nationwide presence, with different independent companies operating under the BCBS umbrella in various states

Question 2

Service providers

Answer 2

offer benefits to subscribers in return for the payment of a premium. Benefits are in the form of services provided by hospitals and physicians in the plan

Question 3

A health maintenance organization (HMO)

Answer 3

aim to balance cost control with quality care, but the trade-off can be less flexibility in choosing providers and accessing services outside of the network

Question 4

A preferred provider organization (PPO)

Answer 4

a collection of health care providers such as physicians, hospitals, and clinics who offer their services to certain groups at prearranged discount prices. In return, the group refers its members to the preferred providers for health care services. Unlike HMOs, preferred provider organizations usually operate on a fee-for-service-rendered basis, not on a prepaid basis. Members of the PPO select from among the preferred providers for needed services. (more freedom of seeing whatever doctor you want, some may provide more coverage than others)

Question 5

The federally administered Medicare program

Answer 5

took effect in 1966. Its purpose is to provide hospital and medical expense insurance protection to those aged 65 and older. It also provides protection to any individual who suffers from chronic kidney disease or to those who are receiving Social Security disability benefits

Question 6

Social Security OASDI program

Answer 6

In addition to Medicare, the federal government also provides disability related benefits through the…

Disability income benefits are available to covered workers who qualify under Social Security requirements. One of the requirements is that the individual must be so mentally or physically disabled that he cannot perform any substantial gainful work

Question 7

Medicaid

Answer 7

is Title XIX of the Social Security Act, added to the Social Security program in 1965. Its purpose is to provide matching federal funds to states for their medical public assistance plans to help needy persons, regardless of age. Medicaid benefits are generally payable to low-income individuals who are blind, disabled, or under 21 years of age. Medicaid is funded by both the federal and state governments and administered by individual states

Question 8

workers’ compensation

Answer 8

All states have these. which were enacted to provide mandatory benefits to employees for work-related injuries, illness, or death. Employers are responsible for providing workers’ compensation benefits to their employees

Question 9

Multiple employer trusts

Answer 9

a method of marketing group benefits to employers who have a small number of employees. METs can provide a single type of insurance (e.g., health insurance) or a wide range of coverages (e.g., life, medical expense, and disability income insurance). An employer who wants to get coverage for employees from a MET must first become a member of the trust by subscribing to it

Question 10

Multiple employer welfare arrangement (MEWA)

Answer 10

a type of MET. It consists of small employers who have joined to provide health benefits for their employees, often on a self-insured basis. They are tax-exempt entities. Employees covered by a MEWA are required by law to have an employment-related common bond

Question 11

TRI-CARE

Answer 11

a federal government accident and health plan which provides accident and health coverage to military services members and their families

Question 12

Case management

Answer 12

involves a specialist within the insurance company, such as a registered nurse, who reviews a potentially large claim as it develops to discuss treatment alternatives with the insured

Question 13

Prospective review

Answer 13

involves analyzing a case before admission to determine what type of treatment is necessary

Question 14

Concurrent review (utilization review)

Answer 14

involves the monitoring of a hospital stay by a nurse while a patient is in the hospital to determine when they will be released, if they require home health care or if a transfer to another facility such as a hospice center or extended care facility is warranted

Question 15

Retrospective review

Answer 15

involves an analysis of care, after the fact, to determine if it was necessary and appropriate. The purpose of this review is not to deny claims but to monitor trends regarding treatment so that future actions may be taken to reduce or eliminate unnecessary healthcare costs, especially in high-cost areas

Question 16

Medicare part A

Answer 16

Often referred to as “Hospital Insurance,” Part A helps cover inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Most people don’t pay a premium for Part A if they or their spouse have worked and paid Medicare taxes for a certain number of years

Question 17

Medicare part B

Answer 17

Known as “Medical Insurance,” Part B covers outpatient services such as doctor visits, preventive care, outpatient hospital services, and some home health care. Part B requires a monthly premium, which varies based on income

Question 18

Medicare part C

Answer 18

a plan offered by private companies that combines coverage from Medicare Part A (hospital insurance) and Part B (medical insurance). It may also include extra benefits like vision, dental, and wellness services. Members often need to use a network of providers and may have different costs and coverage options compared to traditional Medicare

Question 19

Medicare part D

Answer 19

provides prescription drug coverage for Medicare beneficiaries. It is offered through private insurance plans and helps cover the cost of medications. Beneficiaries pay a monthly premium, and coverage and costs can vary between plans

Question 20

Qualifications for Medicaid nursing home benefits

Answer 20

you generally need to have low income and assets, require nursing home care, be a U.S. citizen or legal resident, and live in the state where you are applying

Question 21

Which type of provider is known for stressing preventative medical care and routine physical examinations?

Answer 21

PPOs

Question 22

Commercial health insurance

Answer 22

provided by private companies, rather than government programs like Medicare or Medicaid. These plans are often purchased by individuals or offered through employers. They cover various medical services, such as doctor visits, hospital stays, and prescription drugs, and can vary widely in terms of cost, coverage, and provider networks. Operate on a reimbursement basis

Question 23

Medicare

Answer 23

is a federal health insurance program for people aged 65 and older, and for some younger individuals with disabilities

Question 24

Social security disability insurance