Health Basics

Question 1

Service Basis Plan - BCBS

Answer 1

Blue have a service basis delivery plan where member pays a monthly fee and in return receives care from providers who have an agreement with BCBS. Providers have contracts with BCBS to accept certain fees based on the fee schedule. Blue Cross = hospital, Blue Shield = surgical.

Question 2

Prohibited Pre-existing Condition Exclusions Under HIPAA

Answer 2

Pregnant women, newborns, adopted children, genetic diseases not known

Question 3

ACA Policy on Pre-Existing Conditions

Answer 3

ACA prohibits denial of coverage for individuals for pre-existing conditions regardless of age. As of 9/23/2010, this applies to only individuals under 19. As of 1/1/2014, provision is applicable to all ACA group health plans.

Question 4

Scheduled Payment Program

Answer 4

Requires payment for specific services when rendered at specific charges for services provided or stated in plan’s schedule

Question 5

Expense-Incurred Program

Answer 5

As health care services are required, the insurer reimburses the provider/member for the cost of care

Question 6

Hospital Indemnity Policy

Answer 6

Pays a specific benefit on a daily or monthly basis when an insured is confined to the hospital. The amounts vary - can be as low as $50 or more than $250 per day. Additional riders may be purchased, for example if member ends up in the ICU.

NOT on expense-incurred basis.

Question 7

Creditable Coverage

Answer 7

Under HIPAA: Coverage that reduces the period of any pre-existing condition exclusion because the member had this coverage prior to being covered by the current group plan. This largely went away with the ACA.

Question 8

Fee for Service

Answer 8

Providers are paid a fee for each service provided. Insured goes to the doctor and pays, then submits to insurance for reimbursement.

Question 9

Allowable Pre-Existing Exclusions Under HIPAA

Answer 9

HIPAA allows exclusion for pre-existing condition exclusions for conditions that were diagnosed or treated within 6 months before the effective date of the plan. The maximum amount of time pre-existing conditions exclusions could exist for is 12 months, beginning on enrollment date.

Question 10

Medical Expense Plans

Answer 10

Includes care by physicians (professional) like physical exams, but not facility or skilled nursing.