Chapter 27

Question 1

Premium

Answer 1

the periodic payment of a specific sum of money to an insurance company, for which the insurer in return provides certain benefits

Question 2

Champva -

Answer 2

Civilian health and medical program of the department of Veterans Affairs

Question 3

Tricare

Answer 3

program for active duty and retired members of the uniformed services, their families, and survivors

Question 4

Medicare A

Answer 4

covers inpatient hospital charges

Question 5

Medicare B

Answer 5

covers ambulatory care, including primary care and specialists

Question 6

Medicare C

Answer 6

option for medicare qualified patients to turn their part A and B benefits into a private plan that can offers some additional benefits

Question 7

Medicare D

Answer 7

prescription drug program offered to medicare qualified individuals that requires an additional month premium

Question 8

Medicaid

Answer 8

health program that assists low income families or individuals in paying for doctor visits, hospital stays, long term medical and custodial care costs and more.

Question 9

Group policy

Answer 9

private health insurance plan purchased by an employer for a group of employees

Question 10

Individual policy

Answer 10

one that is not offered by an employer or another group

Question 11

Workers compensation

Answer 11

publicly sponsored system that pays monetary benefits to workers who become injured or disabled in the course of their employment

Question 12

Self insured

Answer 12

many large companies or organizations have enough employees that they can fund their own insurance program. employer provides health or disability benefits to employees with its own funds

Question 13

Participating provider

Answer 13

is a healthcare provider who signed a contract with an insurance company, managed care plan, or government health plan to provide services to policyholders

Question 14

Utilization review

Answer 14

reviews individual cases to ensure that medical care services are medically necessary

Question 15

Co-insurance

Answer 15

the percentage of costs of a covered healthcare service that policyholder pays after the deductible has been paid

Question 16

Co-pay

Answer 16

a set dollar amount that the policyholder must pay for each office visit

Question 17

Deductible

Answer 17

a set dollar amount that the policyholder must pay before the insurance company starts to pay for services

Question 18

EOB (explanation of benefits)

Answer 18

a document sent by the insurance company to the provider and the patient explaining the allowed charge amount the amount reimbursed for services, and the patient’s financial responsibilities

Question 19

Independent practice association

Answer 19

general or family practice provider or provider group that practices independently and may contract with several HMOs

Question 20

Who is eligible for Medicare and Medicaid ?

Answer 20

medicare - patients who are age 65 or older, Medicaid - low income patients

Question 21

Capitation

Answer 21

a payment arrangement for healthcare providers. the provider is paid a set amount for each enrolled person assigned to them, per period of time, whether or not that person has received services

Question 22

HMO

Answer 22

Health maintenance organizations, health plans regulated by HMO laws that require them to include preventive care as part of their benefits package. goal of HMO is to reduce the cost of healthcare while still providing quality healthcare

Question 23

A provider can choose whether to accept Medicaid patients.

Answer 23

True

Question 24

Medigap

Answer 24

if people have medicare part A and B they may choose to purchase a medigap policy, which is a medicare supplement insurance that covers the payment gaps for an individual person.

Question 25

Insurance verification

Answer 25

process of confirming health insurance coverage for the patient. when medical assistant schedules an appointment, health insurance should be collected

Question 26

What plans require healthcare providers to become participating providers?

Answer 26

PPO(Preferred Provider Organization)

Question 27

Which MCO has the highest premiums and the lowest?

Answer 27

Highest- EPO (Eclusive Provider Organization) Lowest-HMO(Health MAintenance organization)

Question 28

Which managed care plans require preauthorizations for surgeries?

Answer 28

Managed care organization Health maintenance organization

Question 29

Beneficiary

Answer 29

a designated person who receives funds from an insurance policy

Question 30

Claim

Answer 30

a formal request for payment from an insurance company for service provided

Question 31

Fee schedule

Answer 31

a list of fixed fees

Question 32

Gatekeeper

Answer 32

the primary care provider, who is in charge of a patient’s treatment, additional treatment, such as referrals to a specialist must be approved by the gatekeeper

Question 33

Indigent

Answer 33

poor, needy, impoverished

Question 34

Policy

Answer 34

a written agreement between two parties, in which one party agrees to pay another party if certain specified circumstances occur

Question 35

Referral

Answer 35

an order for a primary care provider for the patient to see a specialist or to get certain medical services

Question 36

Provider network

Answer 36

• an approved list of physicians, hospitals, and other providers

Question 37

Third-party administrator

Answer 37

an organization that processes claims and provides administrative services for another organization. often used by self funded plans

Question 38

The affordable care act includes?

Answer 38

requires all health plans to cover essential health benefits , ambulatory patient services, hospitalization, mental health and substance use disorder services, prescription drugs, preventive and wellness services and chronic disease management, emergency services, maternity and newborn car, rehabilitative and habilitative services and devices, laboratory services, pediatrics services, including oral and vision care

Question 39

Services that are needed to improve the patient’s current health are considered

Answer 39

Medically necessary

Question 40

What are preventive services?

Answer 40

services provided to help prevent certain illnesses or that lead to an early diagnosis

Question 41

RBRVS

Answer 41

resource based relative value scale - a system used to determine how much providers should be paid for services rendered

Question 42

The health insurance model that offers the most flexibility for patients

Answer 42

Traditional health

Question 43

What are the services that must be covered by Medicaid in each state?

Answer 43

inpatient/outpatient hospital services, nursing facility services, home health services, physician services, rural health clinic service, federally qualified health center services, laboratory and x-ray services, family planning services, nurse midwife services, certified pediatric and family practitioner services, freestanding birth center services, transportation to medical care, tobacco cessation counseling for pregnant women

Question 44

True or False

Health insurance typically covers services and procedures considered medically necessary. Most insurance policies also cover “elective” procedures, such as certain cosmetic surgeries, that are not considered medically necessary

Answer 44

False

Question 45

There are no government managed care plans

Answer 45

False