week 10 Health Insurance Basics Lessons

What is a point-of-service (POS) care plan?

A plan that combines an in-network plan, regulated as an HMO, with an out-of-network plan that is regulated as a PPO. A point-of-service (POS) care plan combines both in-network and out-of-network plans and is regulated as both an HMO and an insurance plan, and it acts as both an HMO and a PPO.

Which statement best describes the payment for services rendered by traditional fee-for-service patients?

Insurance plans usually pay for a percentage of allowed charges. Insurance plans will cover a percentage of the allowed charges in a fee-for-service plan, which is typically 80%.

What is another name used in healthcare to describe a fee-for0service plan?

Indemnity plan Indemnity plan is another name for a fee-for-service plan. Indemnity means an obligation to compensate an individual for loss or damage.

What is a managed care plan?

A plan that negotiates reimbursement amounts and limits patients to those providers and facilities with whom they have contracts Managed care plans are those that negotiate reimbursement amounts to contracted physicians and facilities as well as limit the patient's choices based on those contracts.

What is a fee-for-service plan?

A plan that provides payment to either the physician or patient for each medical service provided Fee-for-service plans provide payment either directly to the physician or to the patient for medical services that have been provided, typically based on a percent such as 80%.

Which individuals qualify for Medicare benefits?

Blind individuals Individuals over 65 Individuals permanently disabled for two years Individuals with chronic renal disease requiring dialysis or a kidney transplant Blind individuals qualify for Medicare benefits, regardless of age or health status. Individuals who are over the age of 65 and qualify for Social Security also qualify for Medicare benefits Individuals who have been permanently disabled for two years qualify for Medicare. Individuals with chronic renal disease that requires dialysis or a kidney transplant qualify for Medicare.

How do HMO managed care plans keep costs down?

By requiring PCPs to see patients before referring them to another specialty practice HMO plans require the primary care physician to act as gatekeeper. The PCP must see the patient first for nearly all illnesses before referring him or her to a specialist.

What do all government-sponsored health plans have in common?

Coverage is federally and/or state funded Coverage can be accepted, or not, depending on the choice of the physician. All government-sponsored health plans are either completely federally funded or are funded partially or completely by the state. It is not a requirement for physicians to accept government-sponsored plans; therefore, physicians can either choose to accept or deny assignment of benefits for government-sponsored health plans.

Which refers to the amount charged by physicians that is comparable to the same specialty and practice in the same geographical area?

Customary fee The customary fee is the amount charged by physicians in the same specialty and same geographical area.

What are some advantages of group policies through private insurance?

Includes no required pre-authorization Offers greater benefits at lower premiums Offsets the cost of the premium, making it more affordable Provides the options of determining the type of health insurance benefits available in the plan There is no requirement of pre-authorization for physician visits in group policies. Since there are many people who are in the pool with a group policy, there are greater benefits available at a much lower premium. In a group policy, the employer offsets the cost of the premium by paying a portion or even the entire premium, thus making it more affordable for employees to cover themselves and their families. Since employers are creating a specific policy for their employees, they have the option of determining what type of health benefits will be included in the plans; for example, chiropractic care and substance abuse counseling.

Which statement applies to employer-sponsored health groups?

Employers usually sponsor a portion of the premium, thus making it more affordable for their employees. Employers will usually cover a large portion of the premium, leaving the employee to pay the remaining portion, thereby making health insurance more affordable for the employee. For example, if the total monthly cost of the premium is $500, the employer might pay $350, leaving the employee responsible for only $150.

Which is an employer right when it comes to selecting group insurance for employees?

Establishment of how much employees will pay for health insurance coverage for themselves and their families An employer has the right to establish the amount employees will pay for coverage for themselves, their spouses (or domestic partner), and children.

Match the government sponsored health plan with its correct description

Federally funded program for those over age 65 Medicare State grant funding for low-income families Medicaid State-funded program for children managed by CMS CHIP Federally funded program for dependent children/spouses of active military TRICARE

What does the insurance carrier use to determine the allowable charges for fee-for-service patients?

Fees that are determined to be usual, customary, and reasonable Insurance companies use what is referred to as UCR, usual-customary-reasonable, when determining the allowable charges for fees for each specific area.

What is true of an HMO plan?

HMO plans require primary care physicians to act as gatekeepers to access other services. HMO plans require primary care physicians to act as gatekeepers to access other services.

How do insurance companies manage patients' care under managed care plans?

Patients may be responsible for payment if care is provided by a physician out of network. Patients choose a primary care physician who provides the majority of care and the determination of medical needs. Care is usually restricted to specific providers, labs, and hospitals that have accepted the insurance plan's fees and/or capitation. Plans may require prior authorization, utilization review, and/or referrals from the PCP for any additional care, including specialists, procedures, therapy, or surgery. If patients choose to seek medical care outside of the insurance company's network, the insurance companies reserve the right to have the patients pay for any service received. A primary care physician is used in a managed care plan to serve as a navigator for the patient and who provides the majority of care and assesses need for other medical services. Providers, labs, and hospitals that accept assignment and have contracted with the plan agree to accept payment from the managed care company as deemed appropriate. Plans under a managed care system may require pre-authorization, referrals, and/or utilization review for additional services not typically covered under what is considered health prevention and maintenance.

Which statement about government-sponsored health plans is accurate?

Patients pay little to no monthly premiums. Government-sponsored health plans are federally or state-funded programs that allow patients to pay little to no monthly premiums based on eligibility, including age and income.

Before the enactment of the ACA, why was it difficult for people to purchase or qualify for privately sponsored health insurance?

Privately sponsored health insurance plans reserved the right to deny coverage based on pre-existing conditions. Privately sponsored health insurance plans exercised the right to deny coverage or charge exorbitant premiums if a person had a pre-existing condition, causing it to be difficult to purchase or qualify for individual insurance.

What have been disadvantages of privately sponsored insurance plans in the past?

Subject to high premiums Coverage denial due to pre-existing conditions Privately sponsored insurance plans can raise premiums based on many factors, thereby making it difficult to afford. Privately sponsored plans can deny applicants coverage based on pre-existing conditions (health issues prior to coverage).

A 40-year-old retiree of the armed forces would most likely qualify for which government-sponsored health plan?

TRICARE TRICARE Standard, Prime, and Extra are programs available to those retirees from the armed forces and their families.