Chapter 2 Health Insurance Providers

the health insurance program which is administered by each state and funded by both the federal and state governments

Medicaid

Multiple Employer Welfare Association (MEWA)

a type of MET. it consists of small employers who have joined to provide health benefits for their employees often on a self insured basis-tax exempt entities.

HMO

also known for stressing preventative medical care.

Preferred Provider Organization (PPO)

collection of health care providers such as physicians, hospitals and clinics who offer their services to certain groups at prearranged discount prices. in return the group refers its members to the preferred providers for health care services. Operate on a fee for service rendered basis and not on a prepaid basis. Can include dental care

Medicare Part A and Part B do NOT pay for

dental work

Tricare

federal government accident and health plan which provides accident and health coverage to military services members and their families (active)

Medicaid

funded by both state and federal governments

what is medicare

hospital and medical expense insurance program

Medicare Part A does not cover

*Services of private duty nurse or attendant *Private rooms *the first three pints of blood *Personal conveniences (IE telephones or tv rentals)

Medicare Part B does NOT cover

*The services of a private duty nurse or attendant *Intermediate or custodial care *cost of skilled nursing care at home over 100 days per benefit period *vision and hearing care, dental care, prescription drugs, cosmetic surgeries and routine physical examinations *injuries as a result of war *care provided outside the US *physician costs exceeding medicare's approved amount

Review

*a 5 month waiting period is required before an individual will qualify for benefits during which time he/she must remain disabled. *to be fully insured on a permanent basis, 40 quarter credits are required.

what is the maximum social security disability benefit amount an insured can receive?

100%

Gatekeeper system

A subscriber must choose a Primary Care Physician (PCP) who serves as the insured's primary physician, or 'gatekeeper,' and who provides basic medical services, coordinates and, if required by the plan, authorizes referrals to specialists and hospitals.

which of these statements is incorrect regarding a preferred provider organization (PPO) a. PPOs normally have more providers to choose from as compared to an HMO b. prices are negotiated in advance for PPO providers c. in network PPO providers offer members better coverage of incurred expenses d. PPOs are not a type of managed care systems

D. PPOs ARE considered to be a managed health care system

a medical care provider which typically delivers health services at its own local medical facility is know as

HMO

which of the following types of organizations are prepaid group health plans where members pay in advance for the services of participating physicians and hospitals that have agreements? PPO, HMO, MEWA, POS

HMO

J is a subscriber to a plan which contracts with doctors and hospitals to provide medical benefits at a preset price. What type of plan does J belong to?

HMO contracts with doctors and hospitals to provide medical benefits to subscribers at a predetermined price

Medicare Part B (Medical Insurance)

Outpatient care. Extends Medicare to supplemental treatments, and physicians initial enrollment ends three months after 65th birthday. Open enrollment is Jan. 1st - March 31st After the annual deductible is met Medicare part B insured will pay 20% of the remaining covered expenses

Under what system do a group of doctors and hospitals in a designated area contract with an insurer to provide services at a prearranged cost to the insured?

PPO

what does Medicare Parts A and B cover?

Part A covers hospitalization; Part B covers doctor's services

Blue Cross/Blue Shield

Prepaid med. benefits for "subscribers" @ approved facilities; many non-profit; Blue Cross - Hospital stays; Blue Shield - M.D. costs. Dominate health insurers of the US. Subscribers pay a set fee (usually each month) for medical services covered under the plan.

The individual who provides general medical care for a patient as well as the referral for specialized care is known as a

Primary Care Physician

Medicare Part A (Hospital Insurance)

hospital insurance covered under Medicare. This program helps to pay for inpatient care in hospitals, care in critical access hospitals small facilities that give limited outpatient and inpatient services to people in rural areas care in skilled nursing facilities, hospice care, and some home health care. Most people get Part A automatically when they turn age 65. They do not have to pay a monthly premium for Part A because they or a spouse paid Medicare taxes while they were working. Maximum for inpatient psychiatric care under part A Medicare is 190 days. covers inpatient care in hospitals and skilled nursing facilities and it covers care provided in a hospice and some care provided at home. as well as drugs administered as part of inpatient treatment

federal employees health benefits program (FEHB)

managed competition through which employee health benefits are provided to civilian government employees and annuitants of the us government. fee for service plans and hmo (prepaid)

Multiple Employer Trust (MET)

method of marketing group benefits to employers who have a small number of employees. Can provide a single type of insurance or a wide range of coverages.

which of the following best describes how a preferred provider organization is less restrictive than a health maintenance organization?

more physicians to choose from

Service providers

offer benefits to subscribers in return for the payment of a premium. Benefits are in the form of services provided by hospitals and physicians in the plan

Health Maintenance Organization (HMO)

offers comprehensive prepaid health care services to its subscribing members. This organization finances health care services for their subscribers on a prepayment basis and also organize and deliver the health services. Subscribers pay a fixed periodic fee to the HMO (as opposed to paying for services only when needed) and are provided with a broad range of health services, from routine doctor visits to emergency and hospital care.

blue cross/blue shield

organizations are considered to be nonprofit

Federally administered medicare program 1966

provide hospital and medical expense insurance protection to those ages 65 and older. it also provides protection to any individual who suffers from chronic kidney disease or to those who are receiving social security benefits for at least 24 months.

Workers Compensation

provide mandatory benefits to employees for work related injuries, illness or death. Employers are responsible for providing worker's comp. benefits to their employees and do so by purchasing coverage through state programs, private insurers or by self insuring.

Medicaid is Title XIX 1965

provide matching federal funds to states for their medical public assistance plans to help needy persons regardless of age. Benefits are generally payable to low income individuals who are blind, disable or under 21 years of age.

Disability income

provided to covered workers who qualify under social security requirements. Must be mentally or physically disabled and cannot perform any substantial gainful work.

commercial insurers

reimburses its insureds for covered medical expenses-policyowners obtain medical treatment from whatever source they feel is most appropriate and submit their charges to their insurer for reimbursement

The percentage of an individual's Primary Insurance Amount (PIA) determines the benefits paid in which of the following programs?

social security disability income-pays benefits that are based on a percentage of an individuals PIA

closed panel

when an hmo is represented by a group of physicians who are salaried employees and work out of the hmo facility.