Insurance Flashcards
What are the two different types of health insurance
commercial and government
What are the features of commercial group health insurance
employer chooses plan, employee gets a discount and has to pay a premium for coverage
to qualify: work for someone, be a full time employee, pass a 90d “probationary period”
What are the features of commercial individual health insurance
covers an individual or family, no discount (usually more expensive)
pro: have the freedom to choose ANY insurance company, plan, and options that fit your needs
What is an HPO
Heath maintenance organization, type of commercial health insurance plan
access to drs/HCPs within network (providers that have agreed to decrease their rates but maintain quality)
cost= less expensive (copay, premium, deductible, max OOP)
need a referral from your PCP/internist to see a specialist in-network
No need to file any claims
What is a PPO
Preferred provider organization
can go out of network for care
higher premiums and deductibles
no referrals necessary
may need to file claims
What is a premium
what you pay out of pocket each pay period to have the insurance
think of this like a Netflix subscription
What is a deductible
what you pay out of pocket BEFORE your insurance kicks in
annual; resets each year
What is a copay
what you need to pay after EACH visit to the doctor
What is an out of pocket limit
the most money you’ll spend in a calendar yr
What is co-insurance
shared pay between you and the insurance company (ex: 50/50)
kicks in once you hit your deductible but not your OOP max
What is a CPT code
procedural code (96040 for GC; for first 30min then q15min after?)
What is an ICD-10 code
dx code
What is pre-authorization
decision by heath insurer or plan that a health care service, tx plan, prescription drug, or durable medical equipment is medically necessary
point is to see if it will be covered or pt will have to pay but does NOT give specific amount and can still be denied
Who gets medicare
ppl over 65, those with a disability
Describe part A of Medicare
hospital coverage, home healthcare, hospice
once you work a minimum of 10yrs, you have zero premium for part A- automatically qualified @65 but will have to pay a deductible
Describe part B of Medicare
doctor fees, outpatient testing, and labs
DO need to pay for premium and sign up for. Doesn’t cover everything you need- need to pay 20% co-insurance for drs, testing, labs, NO OOP MAX (payment for this comes from our taxes)
Who sets the prices for doctors and hospital visits for those on Medicare
centers for medicaid and medicare services
fee for services, no prior auths, no referrals
almost all drs take it, allows for flexibility since you don’t need “extra” to refer out or order tests
What is Medicare part C? What else is it called?
Medicare advantage
hospital, doctor, outpatient, dental, vision, hearing, and prescription coverage (mostly); comes from a commercial insurance (UHC, BCBS, Humana, Anthem, Cigna)
premiums are extremely low or no cost
government pays a fixed amount to the heath insurance companies dependent on several different factors
fee for services, capitated payments (almost all are HMO plans OR narrow network PPO (bc medicare only pays 95-105% of costs)
NEED prior auths
What are capitated payments
Medicare pays a fixed amount to providers based on the # of pts they have or see
What is Medicare part D
sign up only if you’re apart of traditional Medicare (60% of ppl w Medicare)
low to no premiums
is tiered, copays exist, donut holes (may not receive a copay for a while (ex: 10 visits) and then have to pay them all at once
prior auth is required for meds
What is considered traditional Medicare
Medicare part A and B
What percentage of people on Medicare have Medicare part C
40% are on Medicare Advantage
What is considered a disability under Medicare
any condition that prevents you from working more than 1yr
DS, HD, CF, ESRD, ALS
What genetic testing is covered under Medicare
will typically only cover cancer genetic testing for ppl WITH a current cancer dx who meets clinical criteria (think NCCN) AND a FH of cancer/AJ ancestry
If there is little to no FH, have to have a cancer suspicious for BRCA
Can also have multigene panel testing if pt has pre/post test GCing, will help w tx, and genes included are relevant based on personal/FH in addition to above requirements
Lynch testing has to start w tumor biomarker testing; testing is only covered for ppl w a Lynch-associated cancer AND a blood relative w a known Lynch PV
Who is qualified for Medicaid
for low-income individuals and families, based on income level and family size
What does Medicaid cover/not cover
state funded (jointly funded by the state and federal government)
covers “essential health services”- varies by state
state may choose to contract w corporations to administer the plans (think Medicare Advantage) or the state may choose to administer the plan themself
multigene panels are covered by MOST states
prior auth forms may be required
GCing IS covered by Medicaid (NIPS can be covered but NOT for microdel/dup syndromes)
What is balanced billing
insurance may not cover the total cost of a tx or test ordered; physician or hospital may bill you for the difference between the amt your insurance pays them and the total amt
hospitals and labs that accept Medicare and Medicaid are typically not allowed to balance bill pts for services covered by Medicare/Medicaid, even if the services were not 100% covered
Define a cost estimator/benefits investigation and its utility
provide an estimate of the pt’s out of pocket cost based on their insurance plan
define COBRA
consolidated omnibus budget reconciliation act
Group health plans must provide a temporary continuation of coverage when it would be lost due to specific events such as employment termination
18mo coverage
Define a health savings account
money set aside that comes out of paycheck before tax and can only be used on medical expenses (excluding insurance premiums)
typically only people w high deductible health plans are eligible
Define back billing
Billing a patient for additional charges long after the visit is complete
Define cost sharing
Costs of healthcare are shared between the patient and insurance company. Incentive for patients to be cautious with healthcare utilization.
Define risk adjustment
Predict a persons likely use and costs of healthcare services. Used in Medicare advantage to adjust the capitated payments to cover expected medical costs of enrollees. This helps to ensure a plans contracted providers Don’t avoid sicker and more costly patients.
What is the purpose of HCPCS coding?
The healthcare common procedure coding system is used to bill for products supplies and services not included in CPT coding. This is mainly used in Medicare.
What is chip insurance used for?
Children in all states and pregnant women in some states
Define up coding
Medical fraud. Billing for more than the actual services provided.
Define insurance churning
When a person undergoes multiple changes in insurance coverage in a short period of time. Leads to discontinuity of care, gaps in coverage can be due to changes in income and employment common for individuals with low income.
Define unbundling
Dividing each genetic test that you are ordering more than you would expect in order to increase reimbursement through the lab
Define WIC
Women, infants, and children
Federal grants two states for food, healthcare, referrals, and nutrition education for low income, pregnant breast-feeding and non-breast-feeding postpartum women into infants and children up to age 5 years old
Define snap
Supplemental nutrition assistance program
Previously known as food stamps provides benefits to eligible low income, individuals, and families via an EBT card
