Chapter 14 Insurance

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Question

Answer

TRICARE

USED TO BE CHAMPUS; STARTED IN 1967

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WHY DOES TRICARE EXIST?

TO HELP OUT MILITARY PERSONNEL AND THEIR FAMILIES

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HOW MANY REGIONS ARE THERE?

4: 3 IN US NORTH, SOUTH, WEST; 1 OVERSEAS

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WHO OVERSEES TRICARE?

DEPARTMENT OF DEFENSE

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HOW MANY BRANCHES OF MILITARY?

7; ARMY, NAVY, MARINE CORPS, AIRFORCE, COAST GUARD, NAT'L OCEANIC AND ATMOSPHERIC ADMINISTRATION, PUBLIC HEALTH SERVICE.

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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.

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TSC

TRICARE SERVICE CENTER

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TRICARE SERVICE CENTERS

BENEFICIARY SERVICE REP- FIND HEALTHCARE HEALTH CARE FINDER- RN OR DR FIND REFFERALS NURSE ADVISORS-ASK A NURSE 24/7

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BSR

BENEFICIARY SERVICE REP

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MTF

MILITARY TREATMENT FACILITIES

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DEERS

DEFENSE ELIGIBILITY ENROLLMENT SYSTEM. KEEP TRACK OF WHO'S WHERE AND ELIGIBILITY

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MILITARY TREATMENT FACILITIES

ON/NEAR BASE. THEY PERFER YOU GET TREATMENT THERE.

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CASE MANAGER

GUIDES PATIENTS

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CRITICAL PATHWAY

GUIDES YOU THROUGH ALL THE SERVICES YOU NEED IN THE MOST COST EFFECTIVE WAY

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PROGRAM INTEGRITY OFFICE. MONITORS FRAUD AND ABUSE.

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CHAMPVA

CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERAN AFFAIRS

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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

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WHICH IS THE CLOSEST TO CIVILIAN HMO?

PRIME IN TERMS OF PCP AND REFFERAL

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TRICARE PRIME

LOWEST COST; NO DEDUCTIBLES; NO ENROLLMENT FEE BUT MUST ENROLL EVERY YEAR.

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TRICARE STANDARD

POTENTIALLY MOST EXPENSIVE; NO ANNUAL ENROLLMENT. HAS HMO, POS, OR CIVILIAN DR, SO MOST FLEXIBILITY.

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TRICARE EXTRA

LIKE CIVILIAN POINT OF SERVICE PLAN. MIDDLE GROUND OF COST. NO ANNUAL ENROLLMENT.

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CATASTROPHIC CAP BENEFIT

SAYS THE MAX OUT OF POCKET PAY FOR ACTIVE DUTY SPONSORS & FAMILIES IS 1000/YR AND FOR RETIRED 3000/YR

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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

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SUPPLEMENT PLAN

TAKES CARE OF SOME OUT OF POCKET COST

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TRICARE CONTRACT

UNDERWRITTEN IN AURORA, CO. USE CMS-1500

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FILING DEADLINE

ONE YEAR AFTER DATE OF SERVICE

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DEDUCTIBLES

PRIME-NONE, BUT WHEN RETIRED REENROLLMENT FEE EXTRA/STANDARD- $150 IND./$300 FAMILY FOR E5 AND ABOVE.

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GOVERNMENT FISCAL YEAR

10/01-09/31

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CONFIRMING ELIGIBILITY

DEERS

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DR.'S OFFICE

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HOME

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URGENT CARE

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INPATIENT HOSPITAL

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OUTPATIENT HOSPITAL

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EMERGENCY ROOM

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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

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An active duty service member is known as a __________; once retired this former member is called a ____________________

Sponsor; service retiree or military retiree

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an individual who qualifies for TRICARE is known as

beneficiary

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a system for verifying an individuals TRICARE eligibility is called

Defense Enrollment Eligibility Reporting system (DEERS)

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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

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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

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Programs that allow TRICARE standards beneficiaries to recieve treatment, services, or supplies from civilian providers are called

cooperative care and partnership

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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

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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

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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%

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For retired members or their dependents on TRICARE standards, what is thier deductible responsibility for outpatient services? Per Person? Per Family?

$150; $300

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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%

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A voluntary TRICARE health maintence organization type of option is known as

TRICARE Prime

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CHAMPVA is the acronym for ___________________, now known as ___________________

Civilian health and medical program of the veterans administration; Dept of Veteran affairs

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Those individuals who serve in the US Armed Forces, finish their service, and are honorably discharged are known as

veterans

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CHAMPVA is not an insurance program but is considered as a

Service benefit program

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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

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the public law establishing a persons right to review and contest inaccuracies in personal medical records is known as the

Privacy Act of 1974

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An organization that contracts with the government to process TRICARE and CHAMPVA health insurance claims is known as

Fiscal intermediary

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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

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The TRICARE Fiscal year

Begins October 1 and ends September 30

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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)

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TRICARE standard beneficiaries pay a certain amount each year for the cost share and annual deductible, which is known as

catastrophic cap

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To qualify for TRICARE for Life (TFL) a beneficiary must be

a TRICARE beneficiary, eligible for Medicare Part A, enrolled in Medicare Part B

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The time for filing a TRICARE standard claim is

within 1 year from the date a service is provided

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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

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TRICARE beneficiaries who use nonauthorized providers and recieve medical services may be responsible for their entire bill

True

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When an individual on TRICARE prime shows you their identification card, it guarantees TRICARE eligibility

False

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TRICARE Prime Remote (TPR) is a program designed for military retirees and their families

False

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Beneficiaries of the CHAMPVA program have complete freedom of choice in selecting their civilian health care providers

True

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Created by: Lea99