Health Insurance Providers Chapter 5

Questions and Answers

What are commercial health policies?

Policies that do not require monthly payments

Policies that do not cover pre-paid health plans

Policies that have no specific benefits assigned

Policies where owners can assign benefits directly to the health care provider (correct)

What is capitation?

Payment given to a physician for each HMO member

What is a gatekeeper system?

Subscribers select a care physician who handles everything

What is Medicare?

Medical services for ages 65 and older, those with chronic kidney disease, or receiving social security disability for at least 24 months Signup and view all the answers

What is MEWA?

Multiple Employer Welfare Arrangement where small employers provide group benefits to employees Signup and view all the answers

How is funding for Medicare Part B provided?

User premiums Signup and view all the answers

Who is Medicaid intended for?

People in poverty Signup and view all the answers

When a preferred provider organization (PPO) insured goes out-of-network, what happens?

The insurer pays a reduced amount Signup and view all the answers

How much does Medicare Part B pay for physician fees?

80% Signup and view all the answers

What is Medicare Part B also known as?

Supplementary medical insurance Signup and view all the answers

What was expanded when Medicaid was established?

The role of the federal government by allowing the state to receive matching funds Signup and view all the answers

What does a doctor who accepts Medicare Assignment agree to?

To charge no more than the amount Medicare pays for the service Signup and view all the answers

What must a medical provider that accepts Medicare Assignment do?

Accept payment based on a defined Medicare schedule as payment in full Signup and view all the answers

Study Notes

Health Insurance Providers Overview

Commercial Health Policies: Allows policy owners to assign benefits directly to healthcare providers; includes pre-paid health plans with specific benefits and monthly payments.
Capitation: A fixed payment made to a physician for each member enrolled in a Health Maintenance Organization (HMO).
Gate Keeper System: A system where subscribers select a primary care physician who manages all their healthcare needs.

Medicare Insights

Medicare: Provides medical services for individuals aged 65 and older, those with chronic kidney disease, and recipients of Social Security Disability for at least 24 months. Covers hospital room and board, physician services, and prescription drugs.
Medicare Part B Funding: Mostly funded by general tax revenue and user premiums, with 80% coverage for physician fees.
Medicare Assignment: Physicians accepting Medicare Assignment agree to charge no more than the Medicare-approved amount for services, covering 80% of costs with beneficiaries responsible for 20% after the deductible.
Supplementary Medical Insurance: Another name for Medicare Part B.

Medicaid and Employer Plans

Medicaid: Designed to assist individuals in poverty, providing financial support for various health services.
MEWA (Multiple Employer Welfare Arrangement): Allows small employers to sponsor group benefits for their employees through an insurer.

Preferred Provider Organizations (PPO)

Out-of-Network Coverage: When PPO insured individuals seek care outside the network, their insurer pays a reduced amount for services rendered.

Description

Explore key terms from Chapter 5 on health insurance providers with these flashcards. Learn about commercial health policies, capitation, and the gatekeeper system in health care. This quiz will enhance your understanding of health care payment structures.