Lesson 5 Health Insurance Providers Flashcards
Service Providers have Subscribers
unlike LI which are policy holders
Service Provider
Have subscribers unlike LI which has policy holders
organization, provides health coverage by contracting with service providers to provide medical services. subscribers pay in advance through premiums.
ex: HMO’s and Blue Cross Blue Shield
HMO
Health Maintenance Organization… NOT insurance!
Must hold open enrollment period of no less than 30 days every 18 months
stresses preventative health care, early diagnosis and treatment on outpatient basis. enrollment is generally voluntary and paid with a fixed periodic fee.
Reimbursement Approach
health care is provided first and then charges are submitted to insurer.
Right of Assignment
Allows policy owners to assign benefit payments from insurer directly to health care provider
True or False:
HMO’s are required to file an annual report of activities and a complete examination of HMO affairs is conducted every 5 years
TRUE
FACT:
Every HMO subscriber must receive a benefits package that includes a copy of the HMO contract and certificate and members handbook
TRUE
FACT:
There is NO NC law stating that maternity benefits must be offered under and HMO. However, if it is offered, the length of stay for in hospital benefits cannot be limited.
TRUE
Penalties in NC for violating the Unfair Trade Practices Act are:
- probation
- suspension
- revocation of license or HMO certificate of authority
- Fine
If infraction is criminal violation, penalties can result in JAIL
Fact:
If subscriber is covered under a plan that provides for optional family coverage any newborn of the member must be covered at _____ and until ____ months of age.
birth, 18
HMO- new dependents are able to enroll within 30 days of ________
marriage, birth or adoption
applies to group, small group, and HMO group policies only
PPO
Preferred Provider Organization
Association of health care providers such as dr’s and hospitals that agree to provide health care to members a fees negotiated in advance.
groups that contract with PPO’s are employers, insurance companies, and other benefits providers. Members select from among the plans preferred providers for services.
True or False:
PPO’s operate on a fee for services rendered rather than prepaid plans like HMO’s
TRUE
Medicare
Federally sponsored health insurance and medical program for persons 65 or older. administered under Social Security Act
Medicare Part A
Provides hospital Coverage
Medicare Part B
Provides Medical Coverage
Medicare Part C
provides new options
Medicare part D
Covers prescription drugs
Medicare Supplement and Long Term Care Policies
have a free look period of 30 days rather than customary 10 day period.
Medicare patients have a lifetime reserve of ____ days of hospital coverage
60
True or False:
PPO’s who participate in Medicare Services require PCP referral.
FALSE, they do NOT require it
what is the monthly premium and annual deductible for medicare part D beneficiaries 2015
premium- $33.13 per month
deductible- $320 per year
once deductible is satisfied beneficiaries are responsible for 25% of first $2,960 of prescription drug costs. medicare pays other 75%.
once they reach $4700 in spending for the year they reach catastrophic coverage and only pay small co insurance for the rest of the year.
In order to qualify for Medicaid benefits the applicant must be able to prove…
they do not have the ability or means to pay for their own medical care. at least 65 blind or disabled. US citizen or permanent resident alien. need type of care that is only offered in nursing home and meet certain asset and income tests.
Deficit Resolution Act
Helps restrain medicaid spending. encourages preventative care like HMO’s among beneficiaries and to choose lower cost alternatives for equivalent care
Workers Compensation Insurance
provides injured workers with medical care expenses, disability income, and rehab benefits if injured in workplace, no matter who is at fault. States govern their own workers comp laws.
MET’s
Multiple Employer Trust
several small groups that need life/health insurance band together to purchase at a more favorable rate
MEWA
Multiple Employer Welfare Arrangement
similar to a MET but a number of employers pool their risks and self insure
“pool their risks” tax exempt. required by law to have an “employment-related common bond”
ASO Plan
Administrative Services Only
agreement where an insurance company or organization , for a fee, handles the admin of claims, benefits, and other function for self insured group
Commercial Health Insurer
Insurance companies that function on the reimbursement approach.
Self Insured Plan
Health Insurance plan characterized by employer, labor union, frat organization or other group retaining the risk of covering its employees medical expenses.
TPA Plan
Third Party Administrator
organization outside the members of a self insurance group which for a fee process claims and paperwork and analyze information
