Types of Insurance - Managed Care / Medicare/ Medicaid (Pg. 66-70)

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Questions and Answers

Which of the following organizations requires patients to primarily use in-network healthcare providers?

Preferred Provider Organizations (PPOs)

Health Maintenance Organizations (HMOs) (correct)

Independent Practice Associations (IPAs)

Point of Service (POS) plans

What is a key feature of Preferred Provider Organizations (PPOs)?

They offer lower costs than Health Maintenance Organizations (HMOs).

They do not allow out-of-network services.

They provide flexibility to see out-of-network providers with proper approval. (correct)

They do not require a primary care physician.

How do Point of Service (POS) plans uniquely operate compared to HMOs and PPOs?

They require no primary care physician to manage care.

They provide the lowest premium rates.

They exclusively allow in-network provider services.

They mix characteristics of both HMOs and PPOs. (correct)

Which of the following statements about managed care organizations is correct?

They control healthcare services to reduce costs and wasteful procedures. Signup and view all the answers

What is the role of a primary care physician (PCP) within managed care organizations?

To make decisions about the necessity of specialist visits. Signup and view all the answers

What is a unique characteristic of Medicaid compared to Medicare?

It provides medical assistance specifically for low-income individuals. Signup and view all the answers

How does eligibility for Medicaid generally differ across states?

Each state sets its own guidelines for eligibility and services. Signup and view all the answers

Which managed care plan type usually has the lowest cost options?

Health Maintenance Organizations (HMOs) Signup and view all the answers

Which process is often involved when seeking referrals in managed care organizations?

Prior authorization or preauthorization by primary care physicians. Signup and view all the answers

What factor contributes to the higher costs associated with PPOs compared to HMOs?

PPOs do not limit patients to certain providers. Signup and view all the answers

What is the main purpose of Medigap policies?

To cover coinsurance for patients Signup and view all the answers

Which of the following groups is generally eligible for Medicaid?

Low-income individuals and families Signup and view all the answers

How do states determine eligibility for Medicaid?

Using state-specific income guidelines Signup and view all the answers

What does it mean that Medicaid is the payer of last resort?

Medicaid will only pay after all other insurance coverage has been exhausted Signup and view all the answers

Which of the following services is typically not covered by Medicaid?

Cosmetic surgeries unless medically necessary Signup and view all the answers

Why might some states allow 'medically needy' individuals to qualify for Medicaid?

To provide coverage for those incurring health expenses exceeding their income Signup and view all the answers

What is one example of a service that Medicaid does not typically cover?

Dental services Signup and view all the answers

What role does office staff have regarding patients with supplemental insurance?

They need to ask patients if they have supplemental insurance Signup and view all the answers

Which of the following best describes the differences in Medicaid services?

Coverage and eligibility guidelines can vary widely by state Signup and view all the answers

What is the primary purpose of the Medicaid state plan amendment (SPA) required after January 1, 2013?

To increase Medicaid rates to match Medicare payment levels. Signup and view all the answers

What happens if a Medicaid claim is submitted after the time limit set by the state?

The claim can be denied or reduced without justification. Signup and view all the answers

Which part of Medicare primarily covers outpatient services and requires optional enrollment?

Medicare Part B Signup and view all the answers

Which of the following is a characteristic of Medicare Part C?

It requires enrollees to stay within an approved provider network. Signup and view all the answers

What is the consequence of not enrolling in Medicare Part D upon eligibility?

A late enrollment penalty is applied at 1% per month. Signup and view all the answers

What is the role of a fiscal intermediary in Medicaid claim submission?

To process payments for submitted claims. Signup and view all the answers

During what situation would a Medicaid provider continue to be reimbursed at 2012 rates?

If the higher fee schedule rates were not implemented by January 1, 2013. Signup and view all the answers

Which statement about Medicare Part D is true?

It has a 'donut hole' where beneficiaries pay more out-of-pocket after a certain threshold. Signup and view all the answers

What distinguishes a Medigap policy from Medicare Parts A and B?

Medigap supplements Medicare coverage for additional expenses. Signup and view all the answers

Who receives payment if a nonparticipating physician does not accept assignment?

The payment goes directly to the patient. Signup and view all the answers

Study Notes

Managed Care Organizations (MCOs)

MCOs aim to reduce healthcare costs through contractual agreements between insurers and providers.
Types of MCOs include:
- Health Maintenance Organizations (HMOs): Require patients to use a network of providers, typically not covering out-of-network services.
- Preferred Provider Organizations (PPOs): Offer more flexibility, allowing patients to see out-of-network providers with PCP approval; generally more expensive than HMOs.
- Point of Service (POS) Plans: Combine features of both HMOs and PPOs; patients must have an in-network PCP and can see out-of-network providers with referrals.

Medicare Overview

100% federally funded program for those 65 and older, disabled individuals, or those with end-stage renal disease.
Part A (Hospital Insurance): Covers inpatient care, hospice, and home health services.
Part B (Supplementary Medical Insurance): Covers outpatient services, physician bills, and is optional for beneficiaries.
Part C (Medicare Managed Care): Offers additional services through contracted plans, combining benefits of Part A and B.
Part D (Prescription Drug Coverage): Provides options for drug coverage with an annual deductible and monthly premium; began in 2006.

Medicaid Overview

Joint federal-state program providing medical assistance for low-income individuals, including the disabled and children.
Eligibility varies by state; guidelines include income and may include those in "medically needy" situations.
States must reimburse providers at Medicare rates for certain services if they opt for increases.
Medicaid benefits can differ widely by state, with some services typically excluded (e.g., cosmetic surgery, dental care).

Claims and Submission for Medicaid

Claim submissions require photocopying the patient’s insurance card and checking for prior authorization needs.
Claims should use the CMS-1500 form, must be signed by a physician, and sent to a fiscal intermediary.
Submission time limits vary by state and can lead to claim rejection if deadlines are missed without justification.

Medigap Insurance

Medigap, or Medicare Supplemental Insurance, fills coverage gaps left by Parts A and B.
Offers ten types of policies catering to different coverage needs, including coinsurance and deductibles.
Important for office staff to identify if patients have supplemental insurance for billing purposes.

Key Points on Program Eligibility

Medicare: Available to those aged 65+, disabled individuals, or kidney donors; applications processed through Social Security.
Medicaid: Based primarily on income; varies by state with different eligibility criteria and benefits.

Important Features for Patients

Late enrollment penalties apply to Medicare beneficiaries who delay enrollment, equivalent to 1% per month.
Participating physicians accept assignments, receiving payment directly, while nonparticipating physicians send payments to patients.

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Description

Explore the various types of managed care insurance plans, focusing on how managed care organizations (MCOs) function to reduce healthcare costs. This quiz delves into the fundamental concepts of MCOs and the primary types of plans they offer. Understand the contractual agreements between insurers and healthcare providers and their impact on service delivery.