Chapter 2 Review (Health): Health Insurance Providers Flashcards
Commercial insurance companies function on the
reimbursement approach
The _____ _____ _____ built into most commercial health policies lets policyowners assign benefit payments from the insurer directly to the health care provider, thus relieving the policyowner of first having to pay the medical care provider.
right of assignment
These are the dominant health insurers of the USA. They provide the majority of their benefits on a service basis rather than on a reimbursement basis. This means that the insurer pays the provider directly for the medical treatment given to the subscriber, instead of reimbursing the insured.
Blue Cross and Blue Shield
(loosely affiliated through the national Blue Cross and Blue Shield Association but are independently managed)
These are distinguished by the fact that they not only finance health care services for their subscribers on a prepayment basis, but they also organize and deliver these health services at its own local health care facilities.
HMOs
The payment given to a physician for each member of an HMO assigned to them is called
capitation
When the HMO is represented by a group of physicians who are salaried employees and work out of the HMO’s facility, this is known as a _____ _____ (sometimes called a staff model HMO)
closed panel
staff model
For non-emergency situations in a closed network plan, a subscriber may be required to pay up to _____ of the billed amount if a health provider is chosen outside of the network
100%
When HMOs function on an individual or _____ _____ _____ basis, which is characterized by a network of physicians who work out of their own facilities and participate in the HMO on a part-time basis. This is also known as an _____ _____.
independent practice association (IPA)
open panel.
According to the Health Maintenance Organization Act of 1973, employers with _____ or more employees are required to offer federally certified HMO options IF:
25
they offered traditional health insurance to employees.
Groups that contract with PPOs are often
employers, insurance companies, or other health insurance benefit providers
Personal health care consultation, treatment, or intervention using advanced medical technology or procedures delivered on an outpatient basis. Designed to handle:
- Outpatient surgery
- Routine physicals
- Immunizations
Ambulatory Care
The federally administered _____ program took effect in _____. Its purpose is to provide hospital and medical expense insurance protection to those aged _____ and older. It also provides insurance protection to any individual who suffers from chronic _____ disease or to those who have been receiving Social Security Disability benefits for at least _____ months.
Medicare
1966
65 years
kidney
24 months
This form of government insurance (Hospital Insurance) covers inpatient care in hospitals and skilled nursing facilities, and it covers care provided in a hospice and some care provided at home.
Medicare Part A
Enrollment and education for Medicare is handled by the
Social Security Administration
All parts of the Medicare program (except for public information and enrollment) are administered by
The Centers for Medicare and Medicaid Services
If skilled nursing facility expenses are eligible to be covered by Medicare Part A, the insured MUST: have been hospitilized shortly before entering the facility.
have been hospitalized shortly before entering the facility.
Medicare Part A will cover a maximum of _____ days per benefit period in a skilled nursing facility (days _____ will pay 100%, days _____ will pay a flat dollar amount per day)
100
1- 20
21-100
The lifetime maximum for inpatient psychiatric care under Part A Medicare is
190 days
The primary source of financing for Part A is
Federal payroll and self-employment taxes
Physicians who agree to accept assignment on ALL Medicare claims are called
participating providers
This form of government insurance (Medical Insurance) provides medical insurance for required doctors’ services, outpatient services and medical supplies, and many services not covered by Part A
Medicare Part B
The difference between the physician’s actual charges and Medicare’s approved amount is called
“excess charge”
Open enrollment period for Medicare Part B is
January 1 through March 31
When becoming eligible for Medicare an individual can enroll in a
Part C Medicare Advantage Plan
Medicare Part B is funded by
General tax revenue and user premiums
To be eligible for Social Security Disability benefits, you need to be fully insured, in which you need at least one quarter of coverage for each calendar year after turning _____ years old. The minimum number of credits needed is _____.
21
6
One of the requirements is that the individual must be so mentally or physically disabled that he cannot perform any substantial gainful work
- The impairment must be expected to last at least 12 months or result in an earlier death
- A five-month waiting period is required before an individual will qualify for benefits, during which time he/she must remain disabled
- The worker’s spouse and dependent children are entitled to an income benefit which is a percentage of the worker’s primary insurance amount
Additional Eligibility Requirements for Social Security Disability Income
Medicaid benefits are generally payable to low income individuals who are
blind, disabled, or under 21 years of age
The benefits may be applied to _____ deductibles and _____ requirements.
Medicare
co-payment
Medicaid is financed by both
federal and state governments
Under Medicaid, _____ ______ is an eligibility requirement for the payment of _____ _____ _____.
financial need
nursing home expenses
Is a federal government accident and health plan which provides accident and health coverage to military families.
TRI-CARE
The _____ is a system of “managed competition” through which employee health benefits are provided to civilian government employees and annuitants of the United States government. There are two types of plans that participate in this program: _____ plans and _____ _____ _____ (prepaid).
Federal Employees Health Benefits (FEHB) Program
fee-for-service
health maintenance organizations
There is no time limit on how long _____ _____ medical expense benefits continue for disabled workers
Workers’ Compensation
Under medical expense insurance policies, losses that are covered by workers’ compensation are
generally excluded from coverage
Many self-insured plans are administered by insurance companies or other organizations that are paid a fee for handling the paperwork and processing the claims. When an outside organization provides these functions, it is called
an administrative-services-only (ASO) or third-party administrator (TPA) arrangement.
To bolster a self-insured plan, some groups adopt a _____ _____ _____. These plans are designed to insure against a certain level of large, unpredictable losses, above and beyond the self-insured level. As the name implies, _____ are available for a fraction of the insurer’s normal premium.
minimum premium plan (MPP)
MPPs
A method of marketing group benefits to employers who have a small number of employees. They are usually in the same industry group
*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 _____ must first become a member of the trust by subscribing to it
- A _____ may either provide benefits on a self-funded basis or fund benefits with a contract purchased from an insurance company
- In the latter case, the trust (rather than the subscribing employers) is the master insurance contract holder
- Participants are issued a joinder agreement (document which an individual is admitted as a member and bound to the terms of membership)
- The employer’s premium payments are directed into a trust from which the plan’s benefits and claims are paid. These trusts are also called _____ trusts after the relevant section of the Internal Revenue Code.
- Self-insured plans are common to ____ _____ _____ or _____ _____ _____. They are also common in cases where the insured group is small, with relatively healthy members and few claims.
- Self-funded plans commonly use the services of an insurance company to act as a third-party administrator of the plan. Insurers may provide such services without responsibility for claims payment under an _____ _____ _____ contract.
multiple employer trust (MET)
501(c)(9)
multiple employer trusts (METs) or multiple employer welfare arrangements (MEWAs)
Administrative Services Only (ASO)
Which of these statements is INCORRECT regarding a Preferred Provider Organization (PPO)?
PPO’s are NOT a type of managed care systems.
(So, PPO’s ARE considered a managed health care system.)
