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Xcel Insuance > Health Insurance Providers - Chapter points > Flashcards

Health Insurance Providers - Chapter points Flashcards

1
Q

What is health insurance that may be written by a number of commercial insurers also known as?

A

Traditional Insurers

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2
Q

The design or structure of a policy and its provisions can have an impact on an insurer’s_______ ________ efforts.

A

Cost containment

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3
Q

Medical cost management is also know as ______ ________, _________ _______, _______ _______, and ______ _____.

A

Case Management, managed care, claims control, and cost containment.

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4
Q

Case management is sometimes referred to as?

A

Utilization Review

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5
Q

A _______ _______ involves analyzing a case before admission to determine what type of treatment is necessary and appropriate.

A

Prospective review

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6
Q

A ___________ __________ involves the monitoring of a hospital stay by a nurse while a patient is in the hospital to determine when they will be released, if they require home health care or if a transfer to another facility such as a hospice center or extended care facility is warranted.

A

Concurrent View

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7
Q

____ ______ involves an analysis of care after the fact to determine if it was necessary and appropriate.

A

Retrospective review

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8
Q

Concurrent review is sometimes called?

A

utilization review

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9
Q

_______ ______ or _______ _______ is part of a managed care program in which health care is reviewed as it is being provided.

A

Concurrent review or utilization review

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10
Q

All care is coordinated by the insured’s______ ______ _______.

A

Primary Care Physician

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11
Q

____’s often require subscribers to select a primary care physician.

A

HMO’s

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12
Q

a doctor who provides general medical care for a particular member and controls all referrals for specialized care, and in some cases, hospital care is know as?

A

gatekeeper system

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13
Q

A special kind of pre-approval that individual health plan members — primarily those with HMOs and POS plans — must obtain from their chosen primary care physician before seeing a specialist or another doctor within the same network is?

A

Primary Care Physician (PCP) Referral

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14
Q

Subscribers pay a fixed periodic fee to the _____’s.

A

HMO’s

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15
Q

Subscribers pay a fixed fee to an HMO instead of paying for services only when needed and are provided with a broad range of health services, from routine doctor visits to emergency and hospital car, also known as?

A

service incurred plan

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16
Q

Co-payment requirements can be found in the _______ __ _____ in the policy.

A

certificate of coverage

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17
Q

What is known as medical group model or group practice model?

A

Group Model

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18
Q

______ ______ offers a variety of medical services to subscribers.

A

Group model

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19
Q

Under a _____ ____ medical care is rendered by physicians and hospitals who participate in the HMO.

A

staff model

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20
Q

The ____ _____ involves more than one group of physicians.

A

network model

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21
Q

HMO’s may function on a ______ __ ____ _____ (___).

A

individual or independent practice association (IPA)

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22
Q

HMO’s many functions on an IPA basis, characterized by a network of physicians who work out of their facilities and participate in the HMO part-time; this is known as an ______ ______ network.

A

open panel network

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23
Q

If the HMO is represented by a group of physicians who are salaried employees and work out of the HMO’s facility, then they are called a?

A

Closed panel network

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24
Q

HMO’s must provide an open enrollment for ____ days.

A

30

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25
Q

Physicians, hospitals, and clinics offer their services to certain groups at _____ _____ _____.

A

Prearranged discount prices

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26
Q

PP0’s provide a wider choice of?

A

Physicians

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27
Q

Unlike HMO’s, preferred provider organizations usually operate on a ___-____-_____.

A

fee-for-service baisis

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28
Q

a free-for-service basis is_______________________.

A

where the cost of each service is scheduled

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29
Q

____’s provide a wider choice of physicians.

A

PPO’s

30
Q

PPOs have agreed to offer their services to the group where _____ ____ ___ ______.

A

patient fees are discounted

31
Q

When an HMO and a PPO are mixed together they are known as _____ _____ ______.

A

managed care systems

32
Q

Medicare’s purpose is to provide hospital and medical expense insurance protection to those aged?

A

65 and older

33
Q

Who handles enrollment for the Medicare program and provides information about Medicare to the public?

A

Social Security Administration

34
Q

_________ __________ ___________ does not make Medicare policies.

A

Social Security Administration

35
Q

Who administers all other parts of the medicate program except for public information and enrollment?

A

The Centers for Medicare and Medicaid Services.

36
Q

_________ insurance companies handle services provided by hospitals and home health agencies, etc.

A

Intermediary Insurance

37
Q

Insurance companies that handle benefit claims are know as _______.

A

carriers

38
Q

What is a benefit that covers expenses of semiprivate room, meals, nursing services, drugs, tests, operation room, and other medical services and supplies?

A

Inpatient hospital care

39
Q

______ _______ _____ expenses are sometimes covered by Medicare part A, but ONLY if the insured was hospitalized shortly before entering the facility.

A

Skilled nursing facility

40
Q

The inpatient hospital care benefit period is ____ days.

A

60 days

41
Q

_____ _____ _____ benefits will be provided for medical services, supplies and equipment’s, home health aides, part-time nursing care, and therapy services.

A

Home health care

42
Q

_____ _____ benefits cover inpatient and outpatient services for terminally ill patients.

A

Hospice Care

43
Q

Respite for usual caregivers may not exceed ______ _____ _____.

A

5 consecutive days

44
Q

A doctor who accepts Medicare _________ is agreeing to not charge more than the amount Medicare pays for the service performed

A

assignment

45
Q

A ______ _______ ______ means the employee is totally disabled and unable to return to work.

A

total permanent disability

46
Q

a ______ ______ _______ means the employee is able to return to work, however, the employee is unable to perform all previous or some work duties due to the disability.

A

permanent partial disability

47
Q

A _______ _______ _______ means the employee is totally disabled due to an injury for a short period of time.

A

temporary total disability

48
Q

a _______ _______ ______ means the employee is able to work, but with diminished capability.

A

temporary partial disability

49
Q

Workers’ compensation pay for survivor benefits, also known as ______ ______.

A

death benefits

50
Q

Second Injury Funds are also known as _____ ______ ______.

A

subsequent injury fund

51
Q

Under _____-_____ plans,the employer funds and pays for member claims and benefits.

A

self insured

52
Q

Under a ______ ______-________ _____, an employer may share the risk of covering claims by buying stop-loss insurance coverage from an insurance company.

A

partially self-insured plan

53
Q

Health insurance may be written by a number of commercial insurers. The list includes:
1)
2)
and 3)

A

life insurance companies, casualty insurance companies, and monoline companies

54
Q

they also organize and deliver these health services at its own local health care facilities.

A

HMOs

55
Q

The payment given to a physician for each member of an HMO assigned to them is called

A

capitation

56
Q

________ are known for stressing preventive care

A

HMOs

57
Q

Employers with ____ __ ____ employees to offer enrollment in an HMO if they provide health care benefits for their workers

A

25 or more

58
Q

A preferred provider organization is a collection of health care providers such as physicians, hospitals, and clinics who offer their services to certain groups at ____ _____ _____.

A

prearranged discount prices.

59
Q

are often employers, insurance companies, or other health insurance benefit providers

A

Groups that contract with PPOs

60
Q

While these groups do not mandate that individual members must use the PPO, a ______ _____ is typical if they do not

A

reduced benefit

61
Q

If a patient with a preferred provider organization (PPO) chooses to use a non-PPO, the patient usually can expect to have ______ __-___-___ _______.

A

higher out-of-pocket expenses

62
Q

Physicians who agree to accept assignment on ALL Medicare claims are called

A

participating providers

63
Q

The impairment must be expected to last at least ____ _____ or result in an earlier death

A

12 months

64
Q

A ____ month waiting period is required before an individual will qualify for benefits, during which time he/she must remain disabled

A

five-month

65
Q

With Medicaid, The benefits may be applied to ______ ______ and co-payment requirements

A

Medicare deductibles

66
Q

Under Medicaid,______ _____ is an eligibility requirement for the payment of nursing home expenses

A

financial need

67
Q

Under Medicaid, financial need is an eligibility requirement for the payment of _______ ______ _______.

A

nursing home expenses

68
Q

___________ __________ ________ generally compensate employees for lost wages and medical expenses due to occupational accidents.

A

Workers compensation benefits

69
Q

A method of marketing group benefits to employers who have a _____ number of employees is the multiple employer trust (MET).

A

small

70
Q

Insurers may provide such services without responsibility for claims payment under an ________ _______ _______ (ASO) contract.

A

Administrative Services Only

Xcel Insuance (3 decks)

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