CH. 5 review

CO-INSURANCE

After the yearly deductible is met, the patient shares the bill with the insurance company in what is called co-insurance.

MEDICAID

Cover some low income individuals particularly children and pregnant women and certain disabled individuals

All third party insurers have the same UCR rates

False

Under no circumstances will an insurance policy cover services rendered for pre-existing conditions

False

7. An insurance contract with a company or other groups of common interests where in all employees are insured under a single policy is referred to as

Group Policy

PARTICIPATING PROVIDER (PAR)

One who contracts with a third party payer and agrees to abide by certain rules and regulations of that carrier

Exclusions

Sometimes the insurance policy does not cover certain medical conditions

UCR

The part of a provider's charge that the insurance carrier will allow as covered expenses

Individual health insurance policies historically have higher premiums than employer group policies

True

Managed care is medical care that is provided by a corporation established under state and federal laws

True

Medicaid is a joint federal state health program that is run by the individual states

True

SSDI is an insurance program administered by HIPAA for individuals who are unable to work

True

GROUP CONTRACT

A contact of insurance made with a company a corporation or other groups of common interest in all employees or individuals and their eligible dependents are insured under a single policy

MEDICARE

A federal health insurance program that provides benefits to individual 65 years old or older and individuals younger than 65 with certain disabilities

Disability insurance

A form of insurance that pays the policyholder a specific sum of money in place of his or her usual income if the policyholder cannot work because of illness or accident

(Champva)

A health benefits program in which the Department of Veterans Affairs shares the costs of certain health care services and supplies with eligible beneficiaries

Cobra

A law that provides continuation of group health coverage when an individual leaves his or her place of employment

Coinsurance

A periodic fee that is paid to an insurer for health care coverage

Pre-existing condition

A physical or mental condition of an insured individual that existed before the issuance of a health insurance policy or that existed before issuance and for which treatment was received

Non participating provider (NONPAR)

A provider who is under no contractual agreement with the insurance carrier to accept reimbursement as payment in full

MSA

A special tax shelter is set up for the purpose of pain medical bills

MEDICAL SAVINGS ACCOUNT (MSA)

A special tax shelter set up for the purpose of paying medical bills

CMS-1500 FORM

A universal form created by the government for Medicare claims and since adopted by most third-party carriers.

FSA

An IRS section 125 cafeteria plan

5. The universal form used to submit claims to third-party payers is the

CMS - 1500

USUAL, CUSTOMARY, AND REASONABLE- UCR IS A:

Calculation of what certain third-party payers (Medicare) believe in the appropriate fee for healthcare providers to change for a specific service or procedure in a certain Gil graphic area.

3. With an indemnity policy patients:

Can change positions at any time

2. Which of the following is not a way that these two types of plans differ in their basic approach to paying health care benefits

Choice of premium types

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)

Congress passed the consolidated Omnibus Budget reconciliation act health benefit provisions in 1986. The law amends the Employee Retirement Income Security Act, the Internal Revenue Code, and the Public Health Service Act to provide continuation of group health coverage that otherwise would be terminated when an individual needs his or her place of employment

10. The name of the federal entitlement program that cover certain categories of low income individuals and certain disabled individuals is called

Disability insurance

Pre-existing condition

Illnesses or injuries that occurred before the start of a health insurance contract

1. The two basic types of health insurance are

Indemnity and managed care

8. The kind of policy purchased by a self-employed individual or one who works for a company that does not offer a group policy is

Individual policy

WORKER'S COMPENSATION

Insurance pays workers who are injured or disabled on the job or have job related illnesses

INDEMNITY (fee-for-service)

Is the traditional kind of health policy wherein patients can choose any health care provider or hospital they want including specialist and change positions at any time with indemnity (fee-for-service) plans the INSURED (or POLICYHOLDER) typically pays a monthly fee called a PREMIUM

6. The type of insurance that tells patients what physicians they can see and monitors enrollees' medications and treatments so that costs remain as low as possible as

Managed care

MANAGED CARE

Medical care that is provided by a corporation established under state and federal laws

12. The type of plan available to self employed individuals that works in conjunction with special low cost high deductible health insurance is called A

Medical savings account (MSA)

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

Medicare

ENROLLEES

People who are covered under the managed care plan

Deductible

The amount the insured must pay before insurance coverage begins

DEDUCTIBLE

The patient also pay a certain amount of money upfront each year toward his or her medical expenses, known as a deductible, before the insurance company begins paying benefits.

Premium

The portion of the fee (often a percentage) that the insured must pay

4. The value of a provider's service is based on specific historical data referred to as

The usual, customary, and reasonable (UCR) fee

Medigap or Medigap care Supplement Plans

These policies must cover certain expenses such as deductibles and the daily coinsurance amount for hospitalization

Indemnity insurance

Traditional health care in which patient can choose any provider they want including specialists and change physicians at any time

Fee for service and indemnity insurance are the same

True

The portion of the medical fee for which the patient is responsible is called coinsurance

True

To receive maximum payment, health care providers must use the CMS-1500 form for all claims

True

Workers compensation laws are designed to ensure injured or disabled employees are provided with monetary awards eliminating the need for litigation

True

After the deductible is met, the patient must pay 20 percent covered medical expenses, and the insurance company pays 80 percent. This payment is based on what is referred to as a:

Usual, customary, and reasonable (UCR) rates.

OUT-OF-POCKET MAXIMUM

When medical expenses reach a certain amount the UCR fee for covered benefits is paid in full by the insurer.

11. Insurance that pays workers who are injured or disabled on the job or experience job related illnesses is called

Workers' compensation

WRITTEN AGREEMENT

Written agreement is a contract between the policyholder and the insurance company

Comprehensive plan

combine basic and major medical coverage into one plan

All managed care plans allow patients to choose any healthcare provider they want

false

Medicare is the military's comprehensive healthcare program

false

Non participating provider

has no contractual agreement with the insurance carrier

Tricare

the US military's comprehensive health care program for active duty personnel and legible family members retirees and family members younger than age 65 and survivors of all uniformed services

MEDICAL NECESSITY- Most third party payers do not pay for medical services, procedures, or supplies unless:

• they are proper and needed for the diagnosis or treatment of a patient's medical condition. • they are provided for the 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 of the health care provider.

The UCR value of the provider's service is based on historical data developed from the following criteria:

•How much the provider charges his or her patients for the same or a similar service. • the variance in the Charges by most providers for the same service in the same geographical area. • Whether the procedure requires more time, skill, or experience than it usually requires. • The value of the procedure compared with other services.