CPB 2023 CHAPTER 2 Flashcards
Federal mandate for all persons to have minimal essential coverage for themselves and their dependents
Patient Protection and Affordable Care Act
Pay a penalty as part of their income tax returns
Does not comply with the individual mandate for health insurance
What was repealed in December 2017 as part of the Tax Cuts and Jobs Act and went into effect in 2019?
Individual mandate for health insurance
Employer decides on the type of coverage and costs for insurance made available to eligible employees based on standard of employer.
Group Health Plans
Limited exclusions for pre-existing medical conditions, followed by the pre-existing condition exclusion under the ACA.
HIPAA Law of 1996
Employer contracts directly with the insurance company to hand out certificates to covered employees
Full Insured Employer Group
Employer assumes financial responsibility for the enrollees’ medical claims and incurred administrative costs
Fully Insured Employer Group
Payment for Fully Insured Employer Groups?
Employer pays a premium at a fixed rate for a year based on the number of employees enrolled in the plan..
Insurance companies group together several small employers to form a larger group.
Small Employer Group
Benefit of Small Employer Groups?
Enables the insurance company to better predict the cost of insurance.
Group contracts with an insurance company and third party to handle the paperwork
Self-Funded ERISA
Employer pays for each out-of-pocket claim as it is incurred instead of paying a fixed premium.
Self-Funded ERISA
Signs a contract with a health plan to agree to accept assignment for all covered services furnished to its members and to submit claims for the services provided
Participating Provider (PAR)
What must a participating provider write-off?
Any amounts billed on covered services that were above the negotiated rate
May bill the patient for the difference between the amount billed and the amount paid by the health plan except for Medicare
Non-participating provider (nPAR)
Advantage of PAR?
Health plan agrees to direct covered members to the provider and agrees to pay the provider directly for the services provided
Fee schedule amount is five percent higher?
Medicare participating providers
nPAR Medicare?
Limiting charge applies
What is the percentage of nPAR for Medicare?
115% of the physician fee schedule amount
What state has a limiting charge of 105% instead of 115%?
New York
Providers not limited to any specific charge limit on their patients and do not submit claims to Medicare for their services. Patients sign private contracts regarding payment
Opt-out Medicare Providers
When is the patient responsible for payment in full for services as Medicare will not pay any amount to either the patient or provider?
Opt-out Medicare providers
When is provider open enrollment?
Mid-November to December 31st
What is provider open enrollment?
Time period when providers can change participation status
Program that offers free health benefits counseling to Medicare beneficiaries, their families, or caregivers
State Health Insurance Assistance Program
Educates patients on PAR vs nPAR vs opt-out and what it means for them and free workshops
SHIP
HMO
Health Maintenance Organization
Contracts with a multi-specialty group that provides care to the members
Group Model HMO
Pays an established rate which is distributed to the individual physicians as part of their salaries.
Group is paid in bulk and group is responsible for reimbursing physician members and facilities.
Group Model HMO
Employs the physicians on salary to provide care to members in the clinics and other facilities owned by the organization
Staff Model HMO
Closed-panel HMO
Staff Model
Physicians are contracted to provide medical services to only HMO patients
Staff Model HMO
