Types of Insurance (Day 4)

Question 1

All Types & Sub-Types

Types of Insurance Plans

Answer 1

There are 2 types of Insurance Plans:

1) Federal
i) Medicare
ii) Medicaid
iii) CHAMPUS
iv) CHAMPVA

2) Commercial
i) BCBS
ii) Humana
iii) Cigna
iv) Aetna
v) UHC (United Health Care)

Question 2

Full Explanation

Medicare

Answer 2

Medicare is a federal plan. It has 3 eligibility criteria:
i) Patient age needs to be 65 or older
ii) Disability for more than 2 years
iii) Patient should suffer from ESRD (End Stage Renal Disease)
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Medicare has 4 parts:
Medicare Part A: Inpatient Services
Medicare Part B: Outpatient Services
Medicare Part C: Inpatient & Outpatient Services
Medicare Part D: Medicines & Drugs

• Medicare Part A,B & D is also known as Traditional/Indemnity Medicare Plans. There is no OOPS and Authorization required for these plans.

• Medicare Part C, also known as Medicare Advantage Plan, run by MCO (Managed Care Organisation) has 3 subparts in it:

i) HMO (Health Maintenance Organisation): In which
• PCP is mandatory.
• Referral Authorization is mandatory.
• OOPS is less.
• OON is not given.

ii) POS (Point of Service)
• PCP is optional.
• Referral Authorization is optional.
• OOPS is more than HMO.
• OON is given

iii) PPO (Preferred Provider Organisation)
• PCP is optional
• Referral Authorization is optional
• OOPS is Max
• OON is given

Question 3

How many parts does Medicare have. Explain.

Answer 3

Medicare has 4 parts:
Medicare Part A: Inpatient Services
Medicare Part B: Outpatient Services
Medicare Part C: Inpatient & Outpatient Services
Medicare Part D: Medicines & Drugs

• Medicare Part A,B & D is also known as Traditional/Indemnity Medicare Plans. There is no OOPS and Authorization required for these plans.

Question 4

Explain Medicare Part C.

Answer 4

• Medicare Part C, also known as Medicare Advantage Plan, run by MCO (Managed Care Organisation) has 3 subparts in it:

i) HMO (Health Maintenance Organisation): In which
• PCP is mandatory.
• Referral Authorization is mandatory.
• OOPS is less.
• OON is not given.

ii) POS (Point of Service)
• PCP is optional.
• Referral Authorization is optional.
• OOPS is more than HMO.
• OON is given

iii) PPO (Preferred Provider Organisation)
• PCP is optional
• Referral Authorization is optional
• OOPS is Max
• OON is given

Question 5

Medicare Tips (Medicare Part A,B & D)

Answer 5

1) Medicare TFL is 365 days from DOS (Date Of Service)
2) Medicare AFL is also 120 days from Date of Denial
3) Medicare never accept paper claims, only electronic claims.
4) Medicare never accept corrected claims, original claims only (07 is a code used for Re-Submitted Claims)
5) Medicare is always primary but, in 18 scenarios Medicare will be secondary i.e. MSP (Medicare Secondary Plan)

Question 6

Medicaid

Answer 6

Medicaid is a state-federal plan. It had 3 eligibility criteria:
i) Below Poverty line
ii) Pregnant Women
iii) Children (with a single parent)

• Medicaid Spenddown: If a person earns above poverty line then by showing his medical expenses he can get Medicaid Policy.

Question 7

CHAMPUS

Answer 7

It stands for Civilian Health & Medical Program for Uniformed Services. It is a federal plan for active officers & their family members who are serving for the nation like army, navy, naval academy & airforce.

Question 8

CHAMPVA

Answer 8

It stands for Civilian Health & Medical Program for Veteran Affairs. It is a federal plan for retired & disabled officers & their family members who had served for the nation like army, navy & airforce.

Question 9

DEERS

Answer 9

It stands for Defence Enrollment Eligibility Reporting System. It is a department where we can verify whether the policy is active or inactive of a high profile individual.

Question 10

BCBS

Answer 10

It stands for Blue Cross Blue Shield. It is a commercial plan which has 2 parts:
1) Homeplan (Appeal, Eligibility status)
2) Local Plan (Claim status)