Chapter 8: Social Insurance Flashcards
Benefit Period
A period of time during which benefits paid under the policy
Enrollee
A person enrolled in a heath insurance plan, an insured [doesn’t include dependents of the insured]
Pre-existing conditions
Conditions for which the insured has received diagnosis, advice, care, or treatment during a specific time period prior to the application for health coverage
Premium
The money paid to the insurance company for the insurance coverage
Social Security disability insured status
Fully insured or currently insured, depending on the number of coverage credits earned
Waiting period
A period of time that must pass after a loss occurs before the insurer starts paying policy benefits
What is Medicare?
Medicare is a federal medical expense insurance program for people age 65 and older even if the individual continues to work. Medicare benefits are also available to anyone, regardless of age, who has been entitled to social security disability income benefits for two years or has a permanent kidney failure [end stage renal disease-ESRD]
What is Medicaid?
A medical benefits program jointly administered by the individual states and the federal government.
Who is Medicare administered by?
Medicare is administered by the Center for Medicare and Medicaid Services [CMS], which is a division of the United States department of health and human services.
What are the four parts that Medicare is divided into?
- Part A [Hospital Insurance] is financed through a portion of the payroll tax [FICA];
- Part B [Medical insurance] is financed from monthly premiums paid by insureds and from the general revenues of the federal government;
- Part C [Medicare advantage] allows people to receive all of their healthcare services through available provider organization;
- Part D [Prescription drugs] is for prescription drug coverage
What parts of Medicare does the term original Medicare referred to and what does it cover and what does it not require?
Original Medicare refers to part A-hospital insurance, and part B-medical insurance only. It covers healthcare from any doctor, healthcare provider, hospital or facility that accepts Medicare patients. It doesn’t usually cover prescription drugs. It does not require the patient to choose a primary care doctor, nor does it require a referral to see a specialist, as long as the specialist is enrolled in Medicare.
Actual charge
The amount a physician or supplier actually bills for a particular service or supply.
Ambulatory surgical services
Care that is provided at I ambulatory center. These are surgical services performed at a center that do not require a hospital stay unlike in-patient hospital surgery.
Approved amount
The amount Medicare determines to be reasonable for a service that is covered under part B of Medicare.
Assignment
The physician or a medical supplier agrees to accept the Medicare-approved amount as full payment for the covered services.
Carriers
Organizations that process claims that are submitted by doctors and suppliers under Medicare.
Coinsurance
The portion of Medicare’s approved amount that the beneficiary is responsible for paying.
Comprehensive outpatient rehabilitation facility services
Outpatient services received from a Medicare participating comprehensive outpatient rehabilitation facility.
Deductible
The amount of expense a beneficiary must first incur before Medicare begins payment for covered services.
Durable medical equipment
Medical equipment such as oxygen equipment, wheelchairs, and other medically necessary equipment that a doctor prescribes for use in the home.
Excess charge
The difference between the Medicare-approved amount for a service or supply and the actual charge.
Intermediaries
Organizations that process inpatient and outpatient claims on individuals by hospitals, skilled nursing facilities, home health agencies, hospice and certain other providers of health services.
Limiting charge
The maximum amount a physician may charge a Medicare beneficiary for a covered service if the physician does not accept assignment.
Nonparticipating
Doctors or suppliers who may choose whether or not to accept assignment on each individual claim.
