Chapter 27- Health Insurance Basics Flashcards
Health insurance lesson:
Which individuals qualify for Medicare benefits?
Blind individuals
Individuals over 65
Individuals permanently disabled for two years.
Individuals with chronic renal disease requiring dialysis or a kidney transplant.
What do all government sponsored health plans have in common?
Coverage is federal and/ or state funded .
Coverage can be accepted or not depending on the choice of the physician
A 40 year old retiree of the armed forces would most likely qualify for which government sponsored health plan?
TRICARE
CHIP-
program for children’s’ health.
TRICARE-
standard, prime, extra are programs available to those retirees from the armed forces and their families.
Medicare:
individuals who of age 65 or older or who have a designated disability.
- federal health insurance program that provides healthcare insurance to individual’s aged 65 years w/ disabilities, and patients with end stage renal disease (ESRD).
ESRD:
End Stage Renal Disease
Medicaid:
individuals who meet specific financial qualifiers or who are disabled.
- provides government that provides coverage benefits for medically indigent people who meet specific criteria.
What are some advantages of group policies through private insurance?!
- includes no required pre- authorization
- offers greater benefits at lower premiums
- offsets the cost of the premium, making it more affordable.
- provides the option of determining the type of health insurance benefits available in the plan.
What have been disadvantages of privately sponsored insurance plans in the past?
- subject to high premiums
- coverage denial due to pre existing conditions
(health issues prior to coverage)
Which is an employer right when it comes to selecting group insurance for employees ?
Establishment of how much employees will pay for health insurance coverage for themselves and their families.
What does the insurance carrier use to determine the allowable charges for fee for service patients?
fees that are determined to be usual, customary, and reasonable.
Which refers to the amount charged by physicians that is comparable to the same specialty and practice in the same geographical area?
customary fee
Customary fee:
amount charged by physicians in the same specialty and same geographical area.
UCR:
usual, customary, and reasonable
How do insurance companies manage patients care under managed care plans?
- Pts may be responsible for payment if care is provided by a physician out of network.
- pts choose a primary care physician who provides the majority of care and the determination of medical needs.
- care is usually restricted to specific providers, labs, and hospitals that have accepted the insurance plans feed and/ or capitation.
- Plans may require prior authorization, utilization review, and/or referrals from the PCP for any additional care, including specialists, procedures, therapy, and surgery:
What is a POS (point of service) care plan?
A plan that combines an in network plan, regulated as an HMO, with an out of network plan that is regulated as a PPO.
How do HMO managed care plans keep costs down?
By requiring PCP’s to see pts before referring them to another specialty practice.
Which statement best describes the payment for services rendered by traditional fee for service patients?
Insurance plans usually pay for a percentage of allowed charges:
Lesson #2-
Which describes the benefits under disability protection?
disability protection provides benefits when an illness has resulted in a persons inability to work.
What do dental plans generally cover within their benefits?
Dental X-rays
Dental cleaning
What best describes benefits under medicare supplement?
medicare supplement covers medical costs that were unpaid by Medicare.
What are some benefits of the affordable care act?
-pts can no longer be charged more for preexisting health conditions.
- insurance companies are prohibited from dropping pt health coverage if the individual gets sick.
- payment subsides are available for those who cannot afford health insurance, based on household income.
Until what age can someone stay on their parent’s insurance policy ?
26 years old
Covers losses to a third party by the insured
Liability insurance
Covers skilled nursing or rehabilitation care:
Long term care insurance
Covers medical costs unpaid by Medicare:
Medicare supplement
Covers death of the insured person:
Life insurance
Place the steps in order for interpreting information on the insurance card:
- review the scanned copy of the patient’s insurance card and state issued ID card and compare them with the electronic health record.
- identify the subscriber on the health insurance card with the patient’s name.
- identify the insurance plan and HMO, if present.
- identify the insured’s policy number and group number.
- Identify the pts co payment and collect the correct amount.
- ensure that the back of the insurance card has the phone number for customer service and the medical claims address.
Place the steps in order for verifying pt eligibility :
- Obtain pts demographics
- obtain health insurance information when the pt is calling in for an appt
-confirm the appt date and time with the pt
-obtain and photocopy both sides of the health insurance card and state issued ID card.
-from the health insurance card, obtain the contact number of the insurance company.
- call the insurance company or long in to the web portal to obtain verification of eligibility.
Place the steps in order for obtaining pre authorization for a surgery:
- assemble information such as the pt id card, verification of eligibility, and the online insurance providers web portal login information.
- determine the procedure for which pre authorization is being requested for from the patients health record.
- assign appropriate diagnosis and procedural codes for the procedure.
-complete the pre authorization from with all information requested.
-proof read the completed form. - obtain a copy of the pre authorization submission confirmation and attach it to the patients health record.
- call the pt to schedule the service
What information must the MA obtain from the provider initiating the request for pre authorization?
Patients diagnosis
Proposed date of service
Description of the service
How do pts with HMO plans get referrals to see specialists?
by visiting their assigned PCP
OCA-
Which federal government insures a large group of people and authorizes dependents of the military personnel to receive treatment from civilian physicians?
TRICARE
A primary care physician who must approve all other physician and/or specialty visits is known as the:
Gate keeper
___ or indemnity plans are traditional insurance plans that pay all or a portion of the claim. The pt may choose a provider of his or her choice.
Fee for service
What type of plan is defined as a large business or corporation that provides money to cover their employees medical claims?
Self funded
What refers to the contract between the health plan and the provider for monthly payment on a regular basis?
Capitation
What is the monthly, quarterly, or annual payment of a specific amount of money to a company for insurance coverage?
Premium
A Medicare plan is divided into four parts. Part A covers which services?
Hospital
Which insurance policy covers employees of the large companies to compensate employment related injuries?
workers compensation
A Medicare plan is divided into four parts. Part C covers which expenses?
Specialist
A Medicare plan is divided into four parts. Part D covers which expenses?
Prescription
EAQ-
1. An employee is seriously injured in an office fire.
The employer pays the employee even though the employees is not able to come to the office for a few months following the fire. Which legislation does the employer follow in its leave policy?
Workers compensation
- A person has a broken foot from a sports injury and cannot work for 10 weeks, The pt has an insurance policy that pays up to a certain amount per day for lost wages. Which type of insurance does the pt have?
Disability
- A pt on Medicare has met the deductible for the year. Which percentage of the allowable amount billed will be covered by Medicare?
80%
- Which type of insurance pays for any loss to a third party caused by the insured person?
Liability
- A military’s service member’s spouse is undergoing heart surgery. Which government insurance plan covers the spouse’s treatment?
TRICARE
- Which government insurance plan would provide healthcare coverage for a pt who falls within a low-income bracket?
Medicaid
- Which description applies to Medigap insurance?
Designed to fill “gaps” in coverage left by Medicare.
-Examples: are the deductible and copays the pt would be responsible for. Medigap is not mandatory for all patients because it is applicable only to Medicare enrollees.
- Which term applies to exclusive provider organizations (EPO’s) health maintenance organizations (HMO’s), and preferred provider organizations? (PPOs)
Managed care organizations
- Which type of insurance will pay the benefiary in the event of the insured’s death?
Life insurance
- Which of the federal government’s health insurance programs is for people age 65 and older?
Medicare
- Which goods and services are covered under the Medicare Part A?
Services in a hospital on an inpatient basis
- A 30-year-old pt is diagnosed with chronic renal disease. Which program offers healthcare benefits for this pt?
Medicare
- Which term is associated with the amount of money that pts must pay each year for services before the insurance company begins to cover the payments?
Deductible
- Which term describes the maximum amount of money that third party payers will consider reimbursing for a particular procedure??
Allowable charge
- Which statement is true of TRICARE?
It is available for the spouses and dependents of active-duty uniformed service members.
- A pt is a permanently disabled veteran who was honorably discharged from military service. The pt spouse and minor children are covered under which insurance program?
CHAMPVA
- Which health insurance policy covers the children of a veteran who died as a result of a service-related disability?
CHAMPVA
- Which services help prevent diseases and disorders and must be covered by insurance companies?
Vaccinations
Nutrition Counseling
Cholesterol Counseling
Depression Counseling
- Which questions are important to ask when verifying that a patient has health insurance?
- When did the patient’s coverage begin?
- Will the pt be covered on the date of service?
- Will the pt be covered on the type of service?
- Is the healthcare provider in or out of network according to the plan?
- Which goods or services would be covered under Medicare Part B?
Durable medical equipment such as a wheelchair
- Which program provides healthcare benefits for a pt who cannot afford treatment?
Medicaid
- Which federally funded insurance covers dependents of military personnel who receive treatment from civilian providers at the expense of the government?
TRICARE
- Which term identifies the process of having a committee review patient care and testing to determine appropriateness and control costs?
Utilization review
- Which is it called when the insurance company pays 80% of the charge and the pays the remaining 20%?
Co insurance
- Which Medicare plan has the highest premium cost for patients?
Medicare Part B
- Which description defines co-insurance?
A percentage of the allowed charge foe health services, which the pt is responsible for paying.
- Which service is covered by Medicare Part B?
Healthcare provider’s services
- The insurance plan that reimburses all or part of the costs of services, provided that the charge is usual and reasonable for the particular service in that part of the country, is known as what?
Fee for service
- Which term describes the payment that the subscriber makes to the Insurance company?
Premium
- Which term identifies a fee schedule based on provider work, liability expense and overhead?
Resource- based relative value system (RBRVS)
- Which is a method of paying medical providers through a prepaid, flat monthly fee for each covered person?
Capitation
- Which statement describes independent practice associations? (IPAs)
They are paid for services based on a capitation or fee for services.
- Which types of information must be provided to the insurance company when requesting a preauthorization?
Diagnostic codes
Procedure codes
Insurance ID number
Medical documentation
- Which provisions of the Affordable Care Act (ACA) are particularly beneficial for young adults?
- Young adults can remain on their parent’s insurance longer.
- The ACA provides more opportunities for younger people to obtain coverage.
- A pt is a permanently disabled veteran who was honorably discharged from military service. The pt’s spouse and minor children are covered under which insurance program?
CHAMPVA
Nutrition counseling:
must be covered by all insurance companies according to the Affordable Care Act, good nutrition is a way to prevent many diseases.
Cholesterol counseling:
is important for early diagnosis of cardiovascular disease, it is considered a preventative service and is covered by insurance companies.
Depression screening:
is important for early diagnosis of mental health disorders and is considered a preventative service.
Gentetic counseling:
not considered a preventative service and therefore is not covered by all insurance companies.
CHAMPVA:
is a health benefits program in which the department of Veterans Affairs (VA) shares the cost of certain healthcare services and supplies with eligible beneficiaries such as a service member’s spouse and minor children.
Canes & walkers purchases are covered in which part of Medicare?
Part D
Physical therapy treatments and medication administered in the medical office are covered by which Medicare?
Part B
CHAMPUS:
was the healthcare program for family members of active-duty personnel, military retirees and their eligible family members under the age of 65, and survivors of all uniformed services prior to TRICARE.
Disability insurance:
replaces lost income weekly or monthly to employed policyholders who are unable to work as a result of illness, injury, or disease for reasons other than those covered by worker’s compensation.
Special risk insurance:
safeguards a person against loss caused by certain diseases, such as tuberculosis or cancer or certain types of accidents, such as an automobile or airplane crash, up to a maximum benefit.
Life insurance:
policy pays out a lump sum of money to a beneficiary at the death of the insured.
Health insurance:
pays toward the medical bills for the injury but not lost wages if the pt is unable to work.
Hospitalization insurance:
pays for the cost of all or part of the insured person’s hospital room and board and specific hospital services, such as the costs involved in having surgery in a hospital.
Workers compensation:
regulates the benefits of employees injured on the job who cannot work as a result of the injury.
Fair labor standards act:
Provides standards for wages and overtime pay, prohibits those under age 18 from performing certain kinds of work, and restricts the hours of workers under age 16.
Family and Medical Leave:
Legislation mandated that a company with at least 50 employees must provide eligible employees with 12 weeks of unpaid, job protected leave for the birth of a child, an adoption, or a personal or family illness.
Americans with Disabilities Act:
discrimination against individuals with disabilities.
Presentation Notes:
What are habilitative services?
Services aimed at helping individuals with disabilities attain, keep, or improve skills and functioning for daily living…
What does indigent mean?
Poor, needy, and impoverished
What is a Medicare beneficiary?
A person who receives Medical health insurance.
What is a Qualified Medicare Beneficiary (QMB)?
A low-income Medicare patient who qualifies for Medicaid as secondary insurance; Medicaid pays for Part B premiums, deductibles, and co-insurance.
How are CHIPs funded?
State
What does CHAMPVA stand for?
Civilian Health and Medical Program of the Veterans Administration.
What is a health insurance exchange?
An online marketplace where you can compare and buy individual health insurance plans. State health insurance exchanges were established as part of the Affordable Care Act
What is capitation?
(A payment arrangement for healthcare providers. The provider is paid a set amount for each enrolled person assigned to him or her, per period of time, whether or not that person has received services…
What is the effective date?
The date the insurance coverage began..
What does EOB stand for?
Explanation of benefits; 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.
Which disability insurance is a form of health insurance, short-term or long-term?
Neither! Disability is income insurance
Board Notes:
Insurance-
Protects against loss or harm from specified circumstances.
Policy-
Legal contract outlining insurance plan.
Premium-
Payment for the insurance policy; can be paid by an individual, employer, or combination of the employer and individual.
Co-Insurance-
A certain percentage of the bill that is the insured’s responsibility even after the deductible has been met.
Co-Pay-
A set dollar amount that the policyholder must pay for each office visit.
Deductible-
A set dollar amount that the policyholder must pay for each office visit.
Group Policy-
A private health insurance plan purchased by an employer for a group of employees and potentially their spouses and dependents.
Beneficiary-
A person who receives Medicare health insurance.
Network-
connect between providers designated group.
Out of Network-
Go outside of covered choices.
“ Stay in your network.”
Participating Provider-
Government and most private health insurance.
- provider accepts your insurance.
HMO-
Health Maintenance Organization.
Managed care organization with low premiums and out-of-pocket costs
Regulated by HMO laws
Requires
Referrals from PCP to specialists
Precertification and preauthorization for hospital admission, outpatient procedures, treatments
Fees for visits to out-of-network providers are patient’s responsibility.
“ Managed healthcare”
- Limited choices, limited flexibility”
- All have Copays
- Cheaper
Capitation-
A payment arrangement for healthcare providers. The provider is paid a set amount for each enrolled person assigned to him or her, per period of time, whether or not that person has received services..
Utilization Review-
Determines medical necessity of care provided
Approves or denies referral requests
Reviews emergency room and urgent care visits.
- Internal department
Medically Necessary-
Those services that are necessary to improve the patient’s current health.
Claim:
a request for reimbursement from the insurance company for services provided.
Allowed charge:
the maximum amount of money that third party payers will consider reimbursing for a particular procedure.
Gatekeeper:
PCP acts as gatekeeper to specialists or other services.
EOB:
Explanation of benefits.
Referral:
an order from a primary care provider for the pt to see a specialist or to get certain medical services.
Indigent:
poor, needy, impoverished
Personal Insurance:
go out, and puchase it on your own.
Commercial Insurance:
business issuance
Medicaid:
low income.
Medicare:
:Part A: covers inpatient hospital charges..
Part B: covers ambulatory care.
Part C: turns Part A and Part B into a private plan..
Part D: prescription drug program.
Age 65 and older
Worker’s Comp-
Employees who are injured or become ill from work-related issues.
Medi Gap-
Private supplemental health insurance plans purchased by individuals to add coverage to and/or reduce cost-sharing of Medicare coverage.
Tricare-
Dependents of military personnel
What is always verified at time of the appointment booking?
Insurance, DOB, Full Name, Effective Date of Insurance, eligibility, benefits
Gatekeeper
The primary care provider. who is in charge of a patient’s treatment.
Responsibilities:
referrals to a specialist.
Who pays after Medicaid?
state and federal government after Medicaid, the remaining cast if the bill is written off.
What are other managed healthcare plans besides HMO?
PPO (Preferred Provider Organization) & EPO (Exclusive Provider Organization
Health insurance exchange?
online marketplace where you can go online & chat with people.
What are QMB’s? ?
Qualified Medicare beneficiaries
Low income
Qualify for Medicaid for their secondary insurance.
Longterm Care Insurance:
is a relatively a ney type of insurance that covers a broad range of Maintenace and health services.
Precertification:
process of determining if a procedure/ service is covered by the insurance plan & what the reimbursement is for that procedure/ service.
Preauthorization:
process that requires the provider to submit documentation to the payer
VA health care:
for veterans
Managed care system:
is a system of healthcare in which pts agree to visit only providers and hospitals within the defined network to receive the maximum benefits and in which the cost of treatment is monitored by the network.
Medical reimbursement:
is money paid to the medical facility for services.
Obama Care: “ affordable care act”
affordable care act, health care reform,
MCO’s:
provide types of insurance.
Potability:
is an aspect of the Health Insurance Portability and Accountability Act
Co-insurance:
when a pt has two insurance policies and managed care is a type of health care.
IPA’s:
are health maintenance organizations that are paid based on capitations or fee for services and may treat non-HMO pts.
