Lesson 5 Health Insurance Providers

Question 1

Service Providers have Subscribers

Answer 1

unlike LI which are policy holders

Question 2

Service Provider

Answer 2

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

Question 3

HMO

Answer 3

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.

Question 4

Reimbursement Approach

Answer 4

health care is provided first and then charges are submitted to insurer.

Question 5

Right of Assignment

Answer 5

Allows policy owners to assign benefit payments from insurer directly to health care provider

Question 6

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

Answer 6

TRUE

Question 7

FACT:

Every HMO subscriber must receive a benefits package that includes a copy of the HMO contract and certificate and members handbook

Answer 7

TRUE

Question 8

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.

Answer 8

TRUE

Question 9

Penalties in NC for violating the Unfair Trade Practices Act are:

Answer 9

• probation
• suspension
• revocation of license or HMO certificate of authority
• Fine

If infraction is criminal violation, penalties can result in JAIL

Question 10

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.

Answer 10

birth, 18

Question 11

HMO- new dependents are able to enroll within 30 days of ________

Answer 11

marriage, birth or adoption

applies to group, small group, and HMO group policies only

Question 12

PPO

Answer 12

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.

Question 13

True or False:

PPO’s operate on a fee for services rendered rather than prepaid plans like HMO’s

Answer 13

TRUE

Question 14

Medicare

Answer 14

Federally sponsored health insurance and medical program for persons 65 or older. administered under Social Security Act

Question 15

Medicare Part A

Answer 15

Provides hospital Coverage

Question 16

Medicare Part B

Answer 16

Provides Medical Coverage

Question 17

Medicare Part C

Answer 17

provides new options

Question 18

Medicare part D

Answer 18

Covers prescription drugs

Question 19

Medicare Supplement and Long Term Care Policies

Answer 19

have a free look period of 30 days rather than customary 10 day period.

Question 20

Medicare patients have a lifetime reserve of ____ days of hospital coverage

Answer 20

60

Question 21

True or False:

PPO’s who participate in Medicare Services require PCP referral.

Answer 21

FALSE, they do NOT require it

Question 22

what is the monthly premium and annual deductible for medicare part D beneficiaries 2015

Answer 22

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.

Question 23

In order to qualify for Medicaid benefits the applicant must be able to prove…

Answer 23

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.

Question 24

Deficit Resolution Act

Answer 24

Helps restrain medicaid spending. encourages preventative care like HMO’s among beneficiaries and to choose lower cost alternatives for equivalent care

Question 25

Workers Compensation Insurance

Answer 25

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.

Question 26

MET’s

Answer 26

Multiple Employer Trust

several small groups that need life/health insurance band together to purchase at a more favorable rate

Question 27

MEWA

Answer 27

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”

Question 28

ASO Plan

Answer 28

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

Question 29

Commercial Health Insurer

Answer 29

Insurance companies that function on the reimbursement approach.

Question 30

Self Insured Plan

Answer 30

Health Insurance plan characterized by employer, labor union, frat organization or other group retaining the risk of covering its employees medical expenses.

Question 31

TPA Plan

Answer 31

Third Party Administrator

organization outside the members of a self insurance group which for a fee process claims and paperwork and analyze information