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Insurance Chapter 14
Chapter 14 Insurance
| Question | Answer |
|---|---|
| TRICARE | USED TO BE CHAMPUS; STARTED IN 1967 |
| WHY DOES TRICARE EXIST? | TO HELP OUT MILITARY PERSONNEL AND THEIR FAMILIES |
| HOW MANY REGIONS ARE THERE? | 4: 3 IN US NORTH, SOUTH, WEST; 1 OVERSEAS |
| WHO OVERSEES TRICARE? | DEPARTMENT OF DEFENSE |
| HOW MANY BRANCHES OF MILITARY? | 7; ARMY, NAVY, MARINE CORPS, AIRFORCE, COAST GUARD, NAT'L OCEANIC AND ATMOSPHERIC ADMINISTRATION, PUBLIC HEALTH SERVICE. |
| ELIGIBILITY | ACTIVE DUTY/RESERVES ACTIVE FOR 30+ DAYS AND FMAILIES. SPOUSES UNMARRIED CHILDREN/STEPKIDS, RETIREES AND FAMILIES, WIDOW/ERS, UNMARRIED CHILDREN OF DEAD, MEDAL OF HONOR FAMILY, EX SPOUSES NOT REMARRIED. |
| TSC | TRICARE SERVICE CENTER |
| TRICARE SERVICE CENTERS | BENEFICIARY SERVICE REP- FIND HEALTHCARE HEALTH CARE FINDER- RN OR DR FIND REFFERALS NURSE ADVISORS-ASK A NURSE 24/7 |
| BSR | BENEFICIARY SERVICE REP |
| MTF | MILITARY TREATMENT FACILITIES |
| DEERS | DEFENSE ELIGIBILITY ENROLLMENT SYSTEM. KEEP TRACK OF WHO'S WHERE AND ELIGIBILITY |
| MILITARY TREATMENT FACILITIES | ON/NEAR BASE. THEY PERFER YOU GET TREATMENT THERE. |
| CASE MANAGER | GUIDES PATIENTS |
| CRITICAL PATHWAY | GUIDES YOU THROUGH ALL THE SERVICES YOU NEED IN THE MOST COST EFFECTIVE WAY |
| PI | PROGRAM INTEGRITY OFFICE. MONITORS FRAUD AND ABUSE. |
| CHAMPVA | CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERAN AFFAIRS |
| CHAMPVA ELIGIBILITY | -SPOUSE/CHILD OF VET DISABLED WHILE ON ACTIVE DUTY -SURVIVING SPOUSE OF MILITARY DEATH -SURVIVING SPOUSE/CHILDREN OF DEAD DISABLED -FAMILY OF ONE WHO DIED IN LINE OF DUTY |
| WHICH IS THE CLOSEST TO CIVILIAN HMO? | PRIME IN TERMS OF PCP AND REFFERAL |
| TRICARE PRIME | LOWEST COST; NO DEDUCTIBLES; NO ENROLLMENT FEE BUT MUST ENROLL EVERY YEAR. |
| TRICARE STANDARD | POTENTIALLY MOST EXPENSIVE; NO ANNUAL ENROLLMENT. HAS HMO, POS, OR CIVILIAN DR, SO MOST FLEXIBILITY. |
| TRICARE EXTRA | LIKE CIVILIAN POINT OF SERVICE PLAN. MIDDLE GROUND OF COST. NO ANNUAL ENROLLMENT. |
| CATASTROPHIC CAP BENEFIT | SAYS THE MAX OUT OF POCKET PAY FOR ACTIVE DUTY SPONSORS & FAMILIES IS 1000/YR AND FOR RETIRED 3000/YR |
| DUAL ELEGIBILITY | TRICARE PRIMARY IF ONLY INSURANCE IF 2, IT DEPENDS ON WHO'S BEING SEEN. CHILDREN, BIRTHDAY RULE IF AGE: MEDICARE PRIMARY IF DISABILITY: TRICARE PRIMARY |
| SUPPLEMENT PLAN | TAKES CARE OF SOME OUT OF POCKET COST |
| TRICARE CONTRACT | UNDERWRITTEN IN AURORA, CO. USE CMS-1500 |
| FILING DEADLINE | ONE YEAR AFTER DATE OF SERVICE |
| DEDUCTIBLES | PRIME-NONE, BUT WHEN RETIRED REENROLLMENT FEE EXTRA/STANDARD- $150 IND./$300 FAMILY FOR E5 AND ABOVE. |
| GOVERNMENT FISCAL YEAR | 10/01-09/31 |
| CONFIRMING ELIGIBILITY | DEERS |
| 11 | DR.'S OFFICE |
| 12 | HOME |
| 20 | URGENT CARE |
| 21 | INPATIENT HOSPITAL |
| 22 | OUTPATIENT HOSPITAL |
| 23 | EMERGENCY ROOM |
| CHAMPUS, the acronym for Civilian Health an Medical Program of the Uniformed Services, is now called ____________ and was organized to control escalating medical costs and to standardize benefits for active duty families and military retirees. | TRICARE |
| An active duty service member is known as a __________; once retired this former member is called a ____________________ | Sponsor; service retiree or military retiree |
| an individual who qualifies for TRICARE is known as | beneficiary |
| a system for verifying an individuals TRICARE eligibility is called | Defense Enrollment Eligibility Reporting system (DEERS) |
| Mrs. Hancock, a TRICARE beneficiary, lives 2 miles from a Uniformed Service Medical Treatment Facility but needs to be hospitalized for mental health care services at Orlando Medical Center, a civilian hospital. What type of authorization does she require | Nonavailbility statement |
| TRICARE standard and CHAMPVA beneficiaries identification cards are issued to _________ and ___________. Information must be obtained from ___ and _____ of the card on the health insurance claim form | dependent 10 years or more; retirees; front; back |
| Programs that allow TRICARE standards beneficiaries to recieve treatment, services, or supplies from civilian providers are called | cooperative care and partnership |
| for patients whose sponsors is a rank of E4 and below th TIRCARE standards deductible for outpatient care is how much per patient | $50 per family: $100 |
| For patients whose sponsor is a rank of E5 and above, the TRICARE standard deductible for outpatient care is how much per patient | $150 Per family:$300 |
| For TRICARE standard dependents of active duty members pay what percentage for outpatient services after the deductible has been met? what percent does TRICARE pay? | 20%; 80% |
| For retired members or their dependents on TRICARE standards, what is thier deductible responsibility for outpatient services? Per Person? Per Family? | $150; $300 |
| For TRICARE standard retired members or their dependents pay what percent for outpatient services after the deductible has been met? What percent does TRICARE pay? | 25%; 75% |
| A voluntary TRICARE health maintence organization type of option is known as | TRICARE Prime |
| CHAMPVA is the acronym for ___________________, now known as ___________________ | Civilian health and medical program of the veterans administration; Dept of Veteran affairs |
| Those individuals who serve in the US Armed Forces, finish their service, and are honorably discharged are known as | veterans |
| CHAMPVA is not an insurance program but is considered as a | Service benefit program |
| Which individuals are entitles to CHAMPVA medical benefits | Husbands, wifes, and unmarried children of a veteran with a total disability, who died because service-connection disability, and who died in the line of duty on active service |
| the public law establishing a persons right to review and contest inaccuracies in personal medical records is known as the | Privacy Act of 1974 |
| An organization that contracts with the government to process TRICARE and CHAMPVA health insurance claims is known as | Fiscal intermediary |
| the time limit for submitting a TRICARE standards or CHAMPVA claim for outpatient service is _____________________________ for inpatient service it is ___________________________ | within 1 year from date of service is provided; 1 year from patients discharge from hospital |
| The TRICARE Fiscal year | Begins October 1 and ends September 30 |
| A Health care professional who helps a patient who is under the TRICARE standard program obtain preauthorization for care is called a | health care finder (HCF) |
| TRICARE standard beneficiaries pay a certain amount each year for the cost share and annual deductible, which is known as | catastrophic cap |
| To qualify for TRICARE for Life (TFL) a beneficiary must be | a TRICARE beneficiary, eligible for Medicare Part A, enrolled in Medicare Part B |
| The time for filing a TRICARE standard claim is | within 1 year from the date a service is provided |
| Medically necessary treatment needed for immediate illness or injury that would not result in further disability or death if not treated immediately is known as urgent care | True |
| TRICARE beneficiaries who use nonauthorized providers and recieve medical services may be responsible for their entire bill | True |
| When an individual on TRICARE prime shows you their identification card, it guarantees TRICARE eligibility | False |
| TRICARE Prime Remote (TPR) is a program designed for military retirees and their families | False |
| Beneficiaries of the CHAMPVA program have complete freedom of choice in selecting their civilian health care providers | True |
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Lea99