Reimbursement Test 1 part 2

rad2329's version from 2016-09-22 19:53

Section 1

Question Answer
What started in the 1930's?WWII traditional insurance companies added health insurance coverage for hospital, surgical, and medical expenses to accident and life insurance plans.
Why was group health insurance offered?As a way to attract scarce wartime labor. Provided as a benefit to full-time employees of the company. This quickly became a popular employee benefit.
Define deductible.The amount the insured pays before the insurer assumes liability for the remaining costs of covered services.
Define policyholder.An individual or entity that purchases healthcare insurance coverage. (Also known as insured).
What was done in the early 1950's to correct the deficiency of early health insurance policies?Insurance companies began offering major medical insurance coverage for catastrophic illnesses and injuries.
What does Major Medical insruance cover?Catastrophic illnesses and injuries, large deductibles. Expenses associated with extended illnesses and lengthy hospital stays. May pay a portion of expenses.
What is Co-insurance?The amount the insured pays as a requirement of the insurance policy. (After the deductible has been paid, insured and insurer (Third-party payer) share covered losses according to a specified ratio, which is paid by the insured.
List the different types of Healthcare plans.Commercial Insurance, Private Health Insurance, Employer-Based Self-insurance Plans, Blue Cross and Blue Shield Plans, Government-sponsored Healthcare Programs.
What four types of information are found on most insurance policies?What medical services the company will cover, When the company will pay for medical services, How much and for how long the company will pay for covered services, Which process is to be followed to ensure that covered medical medical expenses are paid
During the 1970's what did large companies do to save money?The company could save money by self-insuring their employee health plans rather than purchasing coverage from private insurers.
Why are costs for companies lower for Self-insurance?Because additional fees are built into premiums by private insurance companies. These costs are elimated with Self-insurance.

Section 2

Question Answer
Give two reasons why company self-insurance for a group can be less expensive for the company.Employee group annual medical expenses vary slightly and can be predicted, employers are able to budget annual medical claim expenses.
Administrative services only (ASO) contracts are?An agreement between an employer and an insurance organization to administer the employer's self-insured health plan.
What are Not-For-Profit and For-Profit Healthcare Plans?Community-based, noninvestor-owned healthcare plans.
What is a primary difference between nonprofit and for-profit healthcare plans.In a for-profit health plan excess revenues are distributed to shareholders, in a nonprofit plan excess revenues are not distributed to shareholders but are retained for future internal investments.
What has happened since the 1990's regarding not-for-profit and For-Profit Healthcare plans?Substantial growth of investor or for-profit plans. Nonprofit plans have converted to Investor-owned For-Profit plans.
What were the rist prepaid health plans in the U.S.?"The Blues" - Blue Cross and Blue Shield (BC/BS).
Blue Cross covered ?Hospital Care
Blue Shield covered?Physician's Services
What plan was first created in 1929?Blue Cross
What plan was first created in 1939?Blue Shield
What change to plans happened in 1982?The Blue Cross Association and the National Association of Blue Shield Plans merged to create the Blue Cross and Blue Shield Association.

Section 3

Question Answer
In 2009 - Blue Cross and Blue Shield Association included ?60 independent locally operated companies with plans in 50 states, DC, Peurto Rico, and international plans in Panama and Uruguay.
List the Government - Sponsored Healthcare Programs.Medicare, Medicaid, Champus, Veteran's Healthcare
What was implemented on July 1, 1966?Medicare
Who can be covered under Medicare?Social Security beneficiaries 65 years old and older, People under 65 with certain disabilities, People of all ages with end-stage renal disease, and Ineligible aged and disabled beneficiaries who voluntarily pay a monthly premium.
Medicare Part A is generally free of charge and covers ?Inpatient hospital, skilled nursing, home health, hospice care, and inpatient care in a religious non-medical health care institution.
What does Medicare Part B cover?Physician services, outpatient care, and home healthcare.
What does Medicare Part C cover?Includes Part A and Part B and is operated by private insurance companies that are approved by and under contract with Medicare, Medicare Advantage Plans (HMO/PPO).
What does Medicare Part D cover?Prescription Drug Coverage that helps cover the cost of prescription drugs and is run by private insurance companies.
Medicare Part A is measured how?In Benefit Periods, If a patient goes into the hospital or skilled nursing after one benefit period has ended, a new benefit period begins. The patient must pay the inpatient hospital deductibles for each benefit period. There is no limit to the number of benefit periods.
When does the benefit period for Medicare Part A end?When the patient has not received any inpatient or skilled care for 60 days in a row.
In a benefit period for Medicare Part A, what are the limits to the number of days Medicare will pay for inpatient care?Usually limited to 90 days during each benefit period. When this has been exhausted, a nonrenewable lifetime reserve of up to a total of 60 additional days of inpatient hospital care can be used.

Section 4

Question Answer

Section 5