Health insurance today Ch.4

What are some possible sources of over-insurance?

A person is employed in two jobs, both of which provide group health insurance coverage. The husband and wife are employed and eligible foe group health coverage, and each lists the other as a dependent.

Explain how a medical savings account operates

An individual or business purchases a low-cost policy with a high deductible for the big bills and saves the difference in the MSA to cover smaller bills. Money deposited into the MSA account is 100% tax deductible and can be easily accessed by check or debit card to pay most medical bills tax-free (even expenses not covered by insurance, such as dental and vision). If the funds are not used for medical bills, stay in the MSA account and keep growing on tax-favored basis to cover future medical bills or to supplement retirement. Lower premiums Lower taxes Freedom of choice More cash at retirement

THE UNIVERSAL FORM USED TO SUMIT CLAIMS TO THIRD-PARTY PAYERS IS THE

CMS-1500

The universal form

CMS-1500

With an indemnity policy, patients

Can choose any provider they want, can change providers at any time, pay a monthly "premium"

Which of the folowing is not a way that these two types of plans differ in their basic approach to paying healthcare benefits

Choice of premium types

List the three primary ways these two types of insurance are different

Choice of providers Out-of-pocket costs for covered services How bills are paid

What type of healthcare typically falls under the category of long-term care?

Custodial care involves providing an individual with assistance or supervision or both with ADLs that he or she no longer can perform.

What are the benefits of a flexible spending account?

Employers save when an employee elect's pretax payroll deduction because lower adjusted gross income also reduces matching FICA and federal unemployment tax. Employees benefit because expenses for such items as health insurance premiums and unreimbursed medical, vision, dental, and child and dependant care expenses paid pretax results in immediate tax savings

What happens to leftover funds in a flexible spending account at the end of the year?

IRS allows employers to give FSA participants an additional 21/2 months to spend money left over in their FSAs at year's end on qualified health and dependant care expenses.

Name the two basic types of health insurance plans today.

Indemnity and managed care

The two basic types of health insurance are

Indemnity and managed care

The kind of policy purchased by a self-emplyed individual or one who works for a company that does not offer a group policy is a(n)

Individual policy

What medical benefits are included under COBRA?

Inpatient and outpatient hospital care Physician care Surgery and other major medical benefits Prescription drugs Any other medical benefits, such as a dental and vision care

To whom does the COBRA law generally apply?

It applies to plans in the private sector Plans sponsored by state and local governments

Type of insurance that tells patients what physicians they can see and monitors there medications and treatments SO THAT COSTS REMAIN AS LOW AS POSSIBLE IS:

Managed care

The name of the federal entitlement program that covers certain categories of low-income individuals and certain disabled individuals is called

Medicaid

The type of plan available to slef-employed individuals that works in conjunction with special low-cost, high-deductible health insurance is called a(n)

Medical Savings Account (MSA)

The federal health insurance program that provides benefits to individuals age 65 or older and individuals younger that 65 with certain disabilities is called

Medicare

List some exceptions to the birthday rule

Parents who share the same birthday Divorced or separated parents Active employees Different plan types

Who qualifies for a medical savings account?

Self-employed individuals Employees of small businesses comprising fewer than 50 employees where a small group MSA health plan is in place.

THE VALUE OF A PROVIDER'S SERVICE IS BASED ON SPECIFIC HISTORICAL DATA, REFERRED TO AS:

THE USUAL, CUSTOMARY, AND REASONABLE FEE (UCR)

When a child is listed on both parents' health plan, which one pays first?

The parent whose birthday comes first in a calendar year will be considered the primary plan

Historical data refferred to as

The usual, customary, and reasonable (UCR) fee

Name the four stipulations that determine medical necessity

They are proper and needed for the diagnosis or treatment of a patient's medical condition They are provided for diagnosis, direct care, and treatment of a medical condition They meet the standards of good medical practice in the local area They are not mainly for the convenience of the patient or the healthcare provider.

List the various events that qualify an employee for COBRA coverage

Voluntary or involuntary termination of the covered employee's employment for reasons other than gross misconduct Reduced hours Entitled to Medicare Divorce or legal separation of a covered employee Death of a covered employee Loss of status as a dependant child under the plan rules

An insurance contract with a company wherein all employees are insured under a single policy is referred to as a(n)

group policy

Insurance that pays workers who are injured or disabled on the job or suffer from job-related illnesses is called

workers' compensation