1.4 CM Benefit Programs

Question 1

_____employers may purchase reinsurance, excess risk, or stop-loss insurance to offset very large claims.

Answer 1

self-insured

Question 2

Employers that self-insure often contract with ______ _____ _______ (TPAs) or ________ _______ _______ (ASOs) to handle the administrative aspects of insurance, such as utilization review and processing claims.

Answer 2

Third Party Administrators, Administrative Services only

Question 3

Self-funded plans are regulated federally by ERISA and are ______ from most laws regulating fully-insured plans on the state level.

Answer 3

exempt

Question 4

Pharmacy benefit management services develop and maintain a ________- a list of drugs approved for reimbursement–to encourage the use of lower cost drugs.

Answer 4

formulary

Question 5

Pharmacy benefit management services often use payment tier, with _______ drugs being the cheapest, followed by ________medications, and then ___________ medications

Answer 5

generic, formulary, non-formulary

Question 6

The duration of coverage under COBRA is usually ____ months but can last up to ____ months under certain circumstances.

Answer 6

18, 36

Question 7

In the event of death of the employee or legal separation or divorce from the employee, the spouse and dependent children are eligible to receive COBRA coverage for ____ months.

Answer 7

36

Question 8

If the employee or eligible dependent is qualified to receive COBRA due to termination or reduction of hours, and then becomes disabled on or prior to day ___ of COBRA, he is eligible for ___ months of coverage.

Answer 8

60, 29

Question 9

The eligible person must elect COBRA within ___ days of the plan coverage terminating

Answer 9

60

Question 10

Public benefits programs include _____ _______ _____ ______ (SSDI), _______ _______ _______ (SSI), _______, ________.

Answer 10

Social Security Disability Insurance, Supplemental Security Income, Medicare, and Medicaid

Question 11

Individuals who are entitled to both ______ and ______ are called dual eligibles.

Answer 11

Medicare, Medicaid

Question 12

In the case of dual eligibles, _______ always pays last

Answer 12

Medicaid

Question 13

Medicare is health insurance provided by the U.S. Government for people who are: ___ or older, certain younger people with ______, and people with ____ ____ _____ _____.

Answer 13

65, disabilities, End Stage Renal Disease.

Question 14

Meidcare was created in 1966 under title _____ of the _____ ____ ____ and is administered by _____ for ______ ______ ______ (CMS).

Answer 14

XVIII, Social Security Act, Centers Medicare & Medicaid Services.

Question 15

Medicare eligibility ______ based on income

Answer 15

is not