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MOAA 103


Explain the term maximum benefit limit Amount an insurer agrees to pay for lifetime covered expenses.
what rules must be followed for timely payments? GHP must follow state's Clean Claims Act and/or prompt Payment Act and pay claims they accept for processing on a timely basis
Explain the term late enrollee category of enrollment that may have different eligibility requirements
Describe the acronym ERISA EMPLOYMENT RETIREMENT INCOME SECURITY ACT. 1974 that provides incentives and protection for companies with employee health and pension plans
Explain the concept of Section 125 cafeteria plan Employers' health plans structured to permit funding of premiums with pre-tax payroll deductions
What is the percentage of all consumers who are enrolled in PPO insurance? Over 60% of plan subscribers join PPO
Explain the term creditable coverage history of coverage for calculation of COBRA benefits
Describe the acronym COBRA Consolidated Omnibus Budget Reconciliation Act. Law requiring employers with over twenty employees to allow terminated employees to pay for coverage for 18 months
Explain the term tiered network Network system that reimburses more for quality,cost effective providers. Aim to steer patients toward best providers
Explain the term individual deductible fixed amount that must be met periodically by each individual of an insured/dependent group.
Explain the term family deductible fixed, periodic amount that must be met by the combined payments of an insured/dependent group before benefits begin
Explain the term waiting period Amount of time that pass before an employee/dependent may be eligible in a health plan
Explain the term IHP Individual Health Plan is a medical insurance plan purchase by an individual
Explain the term TPA Third party claims administrators are business associates of health plans usually hired by companies with self-funded health plans
Explain the term ASO Administrative Services Only- Contract where a TPA or insurer provides admin services to an employer for a fixed fee per employee
Describe the concept of group health plan regulations GGP must follow federal and state laws that mandate coverage of specified benefits or treatments to access care. When state law is more restrictive then federal, follow state.
Explain the term rider Document modifying an insurance contract
Explain the term group health plan GHP is an plan of an employer to provide health care to employees, former employees or their families
List the major private payers discussed in chapt 9 WellPoint, Inc. UnitedHealth Group. Aetna. Cigna, Kaiser Permanente, Health NET, Humana Inc, coventry.
Compare and contrast health reimbursement accounts to health saving account HRAs are setup by the empoyer and also funded. The employer decides if funds rollover. HSAs can be contributed by employer and/or employee, and rolls over indefinitely and can be used for non medical stuff after age 65
How are providers paid under the POS model? Like HMOs, POS plans charge an annual premium and a copayment for OVs.salary and capitated. It may be structure as a tierd plan
How are providers paid under HMO model? Paid per member per month capitated rate for each subscriber assigned to them
How are providers paid under the PPO model? Providers are paid by a discounted fee for service
Describe the major features of group health regarding eligibility, portability, and required coverage. Rules such as employment status as well as enrolling dependents. Waiting periods, Late enrollees, Premiums and deductibles, and benefit limits are all under eligibility. COBRA and HIPAA fall under the portability and required coverage.
Compare and contrast employer-sponsored and self-funded health plans. Employer-sponsored health plans are contracted with payers to provide benfits to thier em[employees. Self-funded provides medical benefits from the company directly, it does not utilize outside insurance plans
how does Medicare Define duplicated claims? Those sent to one to more Medicare contractors from the Same provider for the Same Beneficiary, same service, and same date of service.
Which coding set is used to bill Medicare claims? HCPCS
Describe the acronym PQRI Physician Quality Reporting Initiative
What are the steps to take when filing a late claim? Be sure to include an explanation of the reason and have evidence to support it. Claims may be paid if the filing is late for a good reason, ex: accidental record damage
How many plans are offered of Medigap insurance 10 Plans
Describe the 3 plans that are offered through Medicare Advantage Medicare coordinate care plan (CCP). Medicare private fee-for-service. Medical Savings account
Describe the two main types of coverage through the original Medicare plan, Part A & B
Limiting charges apply only to which type of provider? NON PAR
Explain the term ABN and describe the 5 sections of the form Advanced Beneficiary Notice-header,body,option box,additional info, signature box.
Explain the term LCD Local coverage determination- notices sent to Drs with info about the coding and medical necessity of the service
Can a PAR provider for Medicare bill for missed appointments? Please explain PAR providers may bill Medicare patients for missed appointments as long as they also charger non medicare patients the same amount
Describe the acronym MMA Medicare Modernization ACT. Law with a number of Medicare changes including a prescription drug benefit
What is the B suffix mean? Wife
What is the A suffix mean? primary wage earner or retired
Describe 5 items which are covered under Part A 1. inpatient hospital care 2. skilled nursing facility 3. home health care 4. hospice 5. psychiatric inpatient care
What was the 2011 deductible and premium for Part A? Deductible- $1,132 Premiums- $450
Describe coverage provided by Medicare Part D Prescription drugs- brand name, generic, and mail-ordered
Describe coverage provided by Medicare Part C Supplemental benefits-aka Medicare Advantage plan aka medigap- it tends to cover what Part B does not pay for
Describe coverage provided by Medicare Part B Outpatient hospital care, physician services, medical equipment and other supplies
Describe the billing rules governing Medicare participating provider They are contracted with Medicare, they must accept All claims form beneficiaries. They must bill according to the Medicare Fee Schedule Lastly provide ABSs when they believe a service is not covered
Describe medical and preventive services that are excluded under Medicare Part B Cosmetic surgery is a medical service that is not covered. H1N1 is a preventive service that is not covered.
Describe medical and preventive services that are covered under Medicare Part b Artificial eye is a medical service that is covered. Mammogram screening is a preventive service that is covered
Describe coverage provided by Medicare Part A Hospital benefit- Inpatient hospital, SNF, home health care and hospice
List the eligibility requirements for the Medicare Plan 64.5 yo, disabled adult, disabled under 18, spouse entitled individual, kidney disease (ESRD), retired federal employee enrolled in CSRS
Created by: jrocha