Health Insurance Chapter 18
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Questions and Answers

A significant change in the patient's condition is required for payment if the patient is seen more than once in a 30-day period.

True

What are the three scenarios in which an assignment of benefits must be scanned or photocopied and attached to insurance claims?

Submitting a workers' compensation claim, submitting a personal injury insurance claim, or when the payer tends to send the insurance check to the patient.

Which of the following is NOT a stage in the life cycle of the insurance claim?

  • Claim payment
  • Claim rejection (correct)
  • Claim submission
  • Claim processing

    • What form must Medicare beneficiaries sign to release information and payment information to third-party carriers?

    <p>Authorization statement.</p> Signup and view all the answers

    The CMS-1500 claim form is the basic form prescribed by the __________.

    <p>Centers for Medicare and Medicaid Services (CMS)</p> Signup and view all the answers

    What method is recommended for completing health insurance claims for submission to insurance carriers?

    <p>Electronic claims</p> Signup and view all the answers

    Which organizations endorse the CMS-1500 claim form?

    <p>The American Medical Association (AMA) and the Health Insurance Association of America (HIAA).</p> Signup and view all the answers

    The CMS-1500 claim form is primarily used for inpatient services.

    <p>False</p> Signup and view all the answers

    What is Medicare?

    <p>Funded by the federal government and administered by the Centers for Medicare and Medicaid Services (CMS).</p> Signup and view all the answers

    What options do people have regarding Medicare eligibility?

    <p>A person may qualify for only Part A, only Part B, or both.</p> Signup and view all the answers

    What does Part A of Medicare cover?

    <p>Covers hospital costs, short-term skilled nursing facility care, home care, hospice care, and blood for transfusions.</p> Signup and view all the answers

    What does Part B of Medicare cover?

    <p>Covers outpatient medical services.</p> Signup and view all the answers

    What is Part C of Medicare?

    <p>Also known as Medicare Advantage, it provides more health care options through managed care plans.</p> Signup and view all the answers

    What does Part D of Medicare provide?

    <p>Voluntary prescription drug coverage.</p> Signup and view all the answers

    What is Medicare cost containment?

    <p>Efforts to hold down rising health care costs recognized by the government.</p> Signup and view all the answers

    What is the Civil Monetary Penalties Law?

    <p>It was passed to prosecute cases of Medicare and Medicaid fraud.</p> Signup and view all the answers

    What is the purpose of the Physician Quality Reporting System (PQRS)?

    <p>To improve the value received for health care expenditures.</p> Signup and view all the answers

    Who can opt out of Medicare according to the Balanced Budget Act of 1997?

    <p>Certain Medicare physicians and practitioners.</p> Signup and view all the answers

    What is a Medicare Secondary Payer (MSP)?

    <p>An employer-sponsored health plan that acts as primary coverage when the employer has 20 or more employees.</p> Signup and view all the answers

    What are the three basic TRICARE plans?

    <p>TRICARE Standard, TRICARE Extra, and TRICARE Prime.</p> Signup and view all the answers

    Who qualifies as a TRICARE beneficiary?

    <p>Active duty service member, spouses, unmarried children up to age 21, and others based on specific criteria.</p> Signup and view all the answers

    What number is used to access DEERS and file claims for TRICARE?

    <p>Social Security number (SSN) or Department of Defense (DOD) number</p> Signup and view all the answers

    Providers access DEERS directly to verify TRICARE beneficiary's eligibility.

    <p>False</p> Signup and view all the answers

    TRICARE Standard is a _____ health plan offered by TRICARE.

    <p>fee-for-service</p> Signup and view all the answers

    What replaced Social Security numbers on TRICARE identification cards?

    <p>Unique DOD identification number</p> Signup and view all the answers

    What is a TRICARE Young Adult?

    <p>A premium-based plan for qualified dependents</p> Signup and view all the answers

    Who is eligible for TRICARE for Life (TFL)?

    <p>Uniformed service retirees and their spouses over age 65</p> Signup and view all the answers

    Patients must obtain a Nonavailability Statement (NAS) for all outpatient services from civilian sources.

    <p>False</p> Signup and view all the answers

    Match the following TRICARE programs with their descriptions:

    <p>TRICARE Standard = Fee-for-service health plan TRICARE Prime = Managed care options with affordable coverage TRICARE Extra = Preferred provider organization without annual fees TRICARE Young Adult = Premium-based plan for qualified dependents</p> Signup and view all the answers

    What is the definition of Total Disability?

    <p>Illness or injury that prevents a person from performing the duties of his or her occupation.</p> Signup and view all the answers

    What is Workers' Compensation?

    <p>Insurance for industrial accidents or diseases arising from employment</p> Signup and view all the answers

    State Disability Insurance (SDI) gives coverage for off-the-job injury or _____ or sickness.

    <p>illness</p> Signup and view all the answers

    What is the Patient Protection and Affordable Care Act (ACA)?

    <p>A law signed in 2010 to increase health care coverage to uninsured Americans</p> Signup and view all the answers

    What is an insurance claim?

    <p>A request for payment under an insurance contract or bond.</p> Signup and view all the answers

    What are claim submission time limits?

    <p>Period of time in which a notice of claim or proof of loss must be filed.</p> Signup and view all the answers

    What are third-party payers?

    <p>Parties other than the physician or patient who pay for medical expenses.</p> Signup and view all the answers

    The three entities involved in health care reimbursement are: ___, ___, and ___.

    <p>Patient, Provider, Public or private payer.</p> Signup and view all the answers

    What does America's Health Insurance Plans (AHIP) represent?

    <p>A national association that represents health insurers on regulatory issues.</p> Signup and view all the answers

    Which of the following is true about commercial insurance?

    <p>It is run by private companies.</p> Signup and view all the answers

    Indemnity insurance offers flexible choices for health care providers.

    <p>True</p> Signup and view all the answers

    What is self-insurance?

    <p>An arrangement where an employer pays for health care expenses usually covered by insurance.</p> Signup and view all the answers

    What does the Employee Retirement Income Security Act of 1974 (ERISA) protect?

    <p>It protects workers' interests in private pension and welfare plans.</p> Signup and view all the answers

    What is a deductible?

    <p>The amount the insured must pay in a calendar or fiscal year before policy benefits begin.</p> Signup and view all the answers

    What is a Health Savings Account (HSA)?

    <p>A tax-sheltered trust account for medical expenses.</p> Signup and view all the answers

    Which act requires an extension of group health insurance for employees who leave their job?

    <p>Consolidated Omnibus Budget Reconciliation Act (COBRA)</p> Signup and view all the answers

    State insurance exchanges offer four levels of coverage: ___, ___, ___, and ___.

    <p>bronze, silver, gold, and platinum.</p> Signup and view all the answers

    The Health Care Reform ensures that health insurance can be canceled if you get sick.

    <p>False</p> Signup and view all the answers

    What are exclusions in an insurance policy?

    <p>Specific hazards or conditions for which the policy will not pay.</p> Signup and view all the answers

    What does the term 'preexisting conditions' refer to?

    <p>An injury or condition existing before the issuance of a health insurance policy.</p> Signup and view all the answers

    Coordination of Benefits (COB) is used to avoid duplicate payment for losses.

    <p>True</p> Signup and view all the answers

    Who is considered 'insured'?

    <p>An individual or organization protected under an insurance policy.</p> Signup and view all the answers

    What does the Birthday Rule determine?

    <p>Which parent’s insurance pays first for a child.</p> Signup and view all the answers

    Study Notes

    Patient Protection and Affordable Care Act (ACA)

    • Signed into law in March 2010 to increase health care coverage for uninsured Americans.
    • By 2014, approximately 16.5 million fewer people were uninsured, the lowest rate in 40 years.
    • Key provisions include affordable state insurance exchanges, Medicaid expansion, and mandatory employer health insurance for businesses with 100+ employees.

    Insurance Claim

    • Request for payment under an insurance contract or bond.

    Claim Submission Time Limits

    • Specifies the timeframe within which a notice of claim or proof of loss must be filed.

    Third-Party Payers

    • Entities (insurance companies or programs) that pay for medical expenses on behalf of patients, not directly affiliated with the physician or patient.

    Entities Involved in Health Care Reimbursement

    • Patient: Receives medical care.
    • Provider: Medical care provider or supplier.
    • Payer: Entity (private or public) covering medical service costs.

    America's Health Insurance Plans (AHIP)

    • A national association representing health insurers on regulatory issues, with approximately 1300 members.
    • Provides research and statistical information to inform policy makers and the public.

    Commercial Insurance

    • Private health plans that include traditional indemnity, self-insured, and managed care plans.
    • Major companies include Aetna, BlueCross/BlueShield, and United American.

    Indemnity Insurance

    • Also known as fee-for-service plans; covers healthcare costs with flexibility in provider choice.
    • Typically involves deductibles and copayments.

    Self-Insurance

    • Employers or groups assume health care cost risks instead of purchasing insurance.
    • Example entities include Procter & Gamble and the Teamsters Union, regulated under ERISA.

    Employee Retirement Income Security Act of 1974 (ERISA)

    • Protects the interests of workers in private pension and welfare plans, allowing tax-deferred contributions for healthcare expenses.

    Deductible

    • The amount paid by the insured before benefits from an insurance policy kick in.

    High-Deductible Health Plans

    • Require higher deductibles than traditional plans; e.g., $1100 for individuals.
    • Have annual out-of-pocket limits (e.g., $5000 for self).

    Health Savings Account (HSA)

    • Tax-sheltered accounts for medical expenses; unused funds carry over yearly without limits.

    Health Care Flexible Spending Account (HFSA)

    • Employer-sponsored funds set aside from pretax wages for qualified expenses; funds do not roll over.

    Consumer-Driven Health Care (CDHC)

    • Products that encourage employees to manage their healthcare budgets actively.

    Group Insurance

    • Usually provided through employers or associations.
    • Allows for continuation of coverage under individual plans if group contract ends.

    Conversion Privilege

    • Clause allowing insured individuals to continue coverage on an individual policy if the group plan is terminated.

    Consolidated Omnibus Budget Reconciliation Act (COBRA)

    • Requires group health insurance to be offered to employees post-employment for limited periods; usually at higher premium rates.

    State Insurance Exchanges

    • Offer multiple levels of coverage and subsidies to make insurance more affordable; regulated by the ACA.
    • Noncitizens, if lawfully present, must purchase insurance, subject to penalties for noncompliance.

    Health Insurance Cards

    • Contain crucial information such as copayment amounts, preapproval provisions, and insurance company contacts.

    Major Medical Insurance

    • Designed to cover significant medical expenses associated with catastrophic health issues.

    Benefit List

    • A list detailing covered services and procedures under an insurance plan.

    Genetic Information Nondiscrimination Act (GINA)

    • Prevents discrimination based on genetic data in health insurance.

    Insured

    • Individuals or organizations contracted for insurance protection against loss.

    Insurance Agent

    • Licensed representative who negotiates and services insurance contracts.

    Insurance Application

    • A completed form used by insurance companies to assess risk before policy issuance, may require a physical exam.

    Insurance Carrier

    • Organization that offers contracts for financial protection against losses.

    Insurance Policy

    • Legally binding agreement outlining coverage and terms; ensures preventive services are covered at no additional charge.

    Waiting Period (W/P)

    • Time before a benefit becomes active, also known as excepted period.

    Dependents

    • Individuals covered under someone else's insurance contract, typically spouses and children.

    Premium

    • Regular payment required to maintain an active insurance policy.

    Exclusions

    • Specific conditions or events not covered by an insurance policy.

    Limitations

    • Restrictions within a policy detailing exceptions or reduced coverage.

    Waivers

    • Provisions that exclude certain illnesses or disabilities from coverage.

    Health Care Reform Provisions

    • Patient protections include:
      • No insurance cancellation due to illness.
      • No limits due to illness costs.
      • Elimination of the lifetime benefits cap.
      • Coverage for adult children up to age 26.
      • No denial of insurance for preexisting conditions.

    Preexisting Conditions

    • Health issues or injuries that existed prior to obtaining a health insurance policy.

    Verification of Insurance Coverage

    • Can be confirmed through online tools, dedicated phone lines, or point-of-service devices.

    Coordination of Benefits (COB)

    • Procedures to prevent duplicate payments from multiple insurance policies for the same loss.

    Birthday Rule

    • Determines primary insurance based on the parent whose birthday falls earlier in the year.

    Provider Contracts

    • Physicians negotiate contracts with insurance plans, must read and understand terms thoroughly.

    Managed Care Plans

    • Prepaid plans that collect copayments and issue capitation checks for registered patients.

    Medicaid

    • Joint federal, state, and local assistance program offering varying coverage by state, known as Medi-Cal in California.

    Medicaid Eligibility and Enrollment

    • Designed for low-income individuals; expanded under ACA to include more nonelderly adults and simplified enrollment processes.

    Medicare

    • Federally funded healthcare program managed by CMS.

    Medicare Eligibility and Enrollment

    • Available at 65 years of age or under specific conditions; includes coverage options through Parts A, B, C, and D.### Hospital Benefit Period
    • Begins on the day a patient enters a hospital facility.
    • Ends when the patient has not been a bed patient for 60 consecutive days.
    • Each new benefit period renews hospital insurance protection.

    Medicare Part B

    • Covers outpatient medical services; supplements Part A hospital coverage.
    • Funded by premiums paid by enrollees and federal government contributions.
    • For 2016, minimum premium is $104.90/month; higher premiums apply to high earners.
    • Income thresholds: $121.80 for individuals earning over $85,000, $170,000 for married couples, frozen until 2020.

    Medicare Part C

    • Established by the Balanced Budget Act of 1997, allows Medicare beneficiaries to join managed care plans.
    • Offers comprehensive coverage including Parts A, B, and D (prescription drugs).
    • Plans must spend 85% of premiums on medical care starting in 2014; out-of-pocket costs and provider network rules vary.
    • No need for secondary coverage if enrolled in Medicare Advantage; patients must use approved providers.
    • Includes Medicare Medical Savings Account (MSA) plans with high deductibles and rollover funds.

    Medicare Part D

    • Provides voluntary prescription drug coverage effective January 1, 2006.
    • Private companies offer plans with basic benefits set by the federal government.
    • Drug formularies have tiers based on drug cost; plans vary in coverage.
    • Late enrollment penalty of 1% per month applies if not enrolled when eligible.
    • Two enrollment options: standalone Part D plans for original Medicare or integrated plans through Medicare Advantage.

    Drugs Covered by Medicare

    • Part A covers medications related to hospital stays, skilled nursing, hospice care.
    • Part B covers specific in-office administered drugs and preventive vaccines.
    • Part D focuses on prescription drugs, subject to certain exceptions.

    Medicare Cost Containment

    • Recognized need to control rising healthcare costs led to legislative measures in the late 1970s.

    TEFRA (Tax Equity and Fiscal Responsibility Act of 1982)

    • Implemented a prospective payment system (PPS) for hospitalizations under Medicare.
    • Balanced Budget Act of 1997 introduced Outpatient Prospective Payment System (OPPS) for outpatient services.

    Peer Review Organization (PRO)

    • Assigned responsibility for quality care under the Prospective Payment System.
    • Reviews patient cases focusing on admissions, readmissions, and medical necessity.

    Civil Monetary Penalties Law (CMPL)

    • Enacted in 1983 to address Medicare and Medicaid fraud.
    • Physicians can be penalized for payment requests violating Medicare agreements.

    Stark Regulations (I, II, III)

    • Stark I prohibits referrals to labs by physicians with financial relationships.
    • Stark II expanded restrictions on payment referrals for various healthcare services.
    • Stark III modifies previous regulations, reducing burdens on healthcare practices and specifying exceptions.

    Physician Quality Reporting System (PQRS)

    • Developed by CMS to improve healthcare value through "quality measures" tracking.

    Medicare Coverage Determinations

    • Coverage is defined by national laws or regulations; local contractors can establish local coverage determinations.

    Medicare Opt-Out Providers

    • Certain physicians may opt out of Medicare for two years, requiring patients to pay out-of-pocket.

    Medicare/Medicaid Dual Eligibility

    • Some individuals qualify for both Medicare and Medicaid, often known as Medi-Medi.
    • Medicare serves as primary coverage; Medicaid pays remaining costs.

    Senior-Assisted Programs

    • Programs like Doctors Assisting Seniors at Home (DASH) provide medical treatment for seniors in low-income housing.

    Medicare/Medigap

    • Medigap policies help cover out-of-pocket costs for Medicare beneficiaries.
    • Offered by private companies, regulated by the federal government.

    Medicare Secondary Payer (MSP)

    • Employed individuals over age 65 may have employer-sponsored insurance as primary, with Medicare as secondary.

    TRICARE Overview

    • Comprehensive health benefits program for uniformed services dependents.
    • Includes three main plan types: Standard (fee-for-service), Extra (preferred provider organization), Prime (HMO).

    TRICARE Eligibility

    • Beneficiaries include active duty members, retirees, spouses, children, and certain disabled dependents.

    Ineligibility for TRICARE

    • Medicare-eligible beneficiaries not in Part B, veterans under CHAMPVA, and certain family members do not qualify.

    DEERS (Defense Enrollment Eligibility Reporting System)

    • The sponsor is responsible for enrolling all eligible family members in DEERS for TRICARE coverage verification.

    TRICARE Identification Cards

    • Social Security numbers removed for security; unique DOD identification numbers used.

    TRICARE Standard

    • Fee-for-service plan covering a range of services with automatic enrollment for eligible individuals.

    TRICARE Benefits

    • Patients receive civilian healthcare services; federal government shares costs with patient deductibles and cost-sharing.

    TRICARE Extra

    • No enrollment fee; offers discounts on services through network providers and flexibility in care choices.

    TRICARE Prime

    • HMO-type managed care option with low costs for active duty members and their families; includes primary care manager assignments.### TRICARE Overview
    • Active duty service members automatically enrolled in TRICARE Prime.
    • Utilization of local military providers or TRICARE civilian network when necessary.
    • No annual deductibles; copayments vary.
    • Optional dental plan available for an extra monthly premium.

    Outpatient Surgery Requirements

    • Outpatient or ambulatory surgeries require verification against the approved procedure list in the TRICARE Policy Manual.
    • TRICARE Prime identification card does not guarantee eligibility; eligibility must be verified by providers.

    Nonavailability Statement (NAS)

    • NAS certifies that nonemergency care is unavailable at a Uniformed Services Medical Treatment Facility (USMTF).
    • Required for nonemergency inpatient care from civilian sources for those within USMTF service areas.
    • No NAS needed for outpatient services from civilian sources.
    • Preauthorization may be necessary in certain areas or for specific procedures.

    TRICARE Young Adult (TYA)

    • TYA is a premium-based plan for dependents aged out of TRICARE.
    • Eligibility established by the uniformed service sponsor; dependent must enroll in DEERS.

    TYA Eligibility Requirements

    • Dependents must be under age 26, unmarried, and not eligible for other TRICARE or employer-sponsored health plans.
    • Must have "aged out" at ages 21 or 23 while being full-time college students.

    TRICARE for Life (TFL)

    • TFL serves as supplemental coverage to Medicare for eligible uniformed service retirees aged 65 and over.
    • Most beneficiaries must qualify for Medicare Part A and enroll in Part B; exceptions exist.

    TFL Coverage and Requirements

    • Enrollment in DEERS necessary; no TRICARE card required.
    • Coverage only for services that are Medicare or TRICARE benefits.

    TRICARE Payment Guidelines

    • Medicare covers services first; TRICARE supports with deductible and cost-share coverage.
    • Claims handling varies based on whether a service is covered by Medicare, TRICARE, or both.

    TRICARE Plus Program

    • TRICARE Plus offers primary care at selected Military Treatment Facilities (MTFs) without enrollment fees.
    • Identification cards issued to enrollees; enrollment is tracked in DEERS.

    CHAMPVA Overview

    • CHAMPVA provides healthcare benefits for spouses and children of veterans with service-connected disabilities.
    • No premiums required for this benefit program.

    CHAMPVA Eligibility

    • Covers spouses and children of veterans with total and permanent service-connected disabilities and survivors of veterans who died from such disabilities.

    CHAMPVA Benefits

    • Covers almost all medically necessary health services with a $50 annual outpatient deductible.
    • Beneficiaries automatically enrolled in Medicare at age 65 to maintain eligibility.

    State Disability Insurance (SDI)

    • SDI provides coverage for off-the-job injury or sickness, funded through paycheck deductions.
    • Available in specific states; benefits begin after seven consecutive days of disability.

    Types of Disability Claims

    • Claims categorized into nondisability, temporary disability, and permanent disability.
    • Temporary disabilities affect ability to work temporarily, while permanent disabilities imply long-term impacts.

    Workers' Compensation Overview

    • Covers work-related injuries through employer-paid insurance, providing cash benefits and medical treatment.
    • Laws are mandatory state programs aiming to provide maximum recovery and income security to injured workers.

    Workers' Compensation Process

    • Involves notification of injury, employer responsibilities for initial medical care, and submission of progress reports.
    • Significant changes in the patient's condition trigger further documentation submissions for continued coverage.

    Claims Submission Process

    • Involves stages of claim submission, processing, adjudication, and payment.
    • CMS-1500 form is the primary method for submitting outpatient service claims to health insurers.

    Claims Authorization and Information Release

    • Patients must consent to release of medical information for claim processing.
    • Assignment of benefits signed allows insurance payments to be directed to medical providers.

    Electronic vs. Paper Claims

    • Electronic claims are preferred for efficient processing; however, paper claims via CMS-1500 are still in use for some situations.
    • Familiarity with paper claim fields aids understanding of electronic data submission.

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    Description

    This quiz covers key concepts related to the Patient Protection and Affordable Care Act (ACA) and its impact on health insurance coverage in the United States. It explores the provisions of the ACA and its role in reducing the number of uninsured Americans since its implementation. Test your knowledge on the significant changes in the healthcare landscape introduced by this landmark law.

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