Chapter 8: Health Insurance Classes, Providers, and Programs Flashcards
(44 cards)
Health insurance provided by the goverment is also called _____ ______
Social Insurance
The federal goverment administers disability benefits through ________ _______
Social Security
______ insurance provides specialized coverage such as AD&D, which only provides coverage for accidental death and dismemberment. These insurance policies are also referred to as conditional contracts because they do not pay benefits unless specific conditions are met.
Limited
If the insured only loses one extremity or vision in one eye, the policy will pay ______ of the principal sum.
50%
______________- policies provide broad coverage for accident and sickness.
Comprehensive
_______ insurers include stock and mutual insurers. These insurers provide a wide range of health insurance plans such as:
Medical expense policies,
Disability income, and
Limited policies.
Commercial
Commercial insurers typically pay benefits on a ___________ basis, meaning that the insured pays the medical providers for services and the insurer reimburses the insured.
reimbursement
________ __________ include BlueCross BlueShield. They differ from commercial insurers in that they pay benefits on a service basis, which means that the insurer pays benefits directly to the medical providers instead of the insured.
Service Providers
TF: Service Providers such as BlueCross BlueShield have contacts with subscribers, but not with medical providers
False - service providers have contracts with both subscribers AND medical providers
TF: Service providers differ from stock and mutual insurers in that they provide the medical services; whereas, stock and mutual insurers provide reimbursement of medical services.
True
BlueCross BlueShield plans are ______ because subscribers pay a fixed monthly fee for all services.
prepaid
BlueCross BlueShield organizations are also referred to as ______ _______ because the doctors and hospitals that sponsor BlueCross BlueShield also supply the insurance coverage. BlueCross provides hospital service and BlueShield provides doctors’ service.
Producer Cooperatives
____ ____ ____ plans allow plan participants to receive care from participating OR nonparticipating providers
Point of Service (POS)
_______ also provides benefits to people who qualify for Social Security or Railroad Retirement Board disability benefits, those with ESRD (end stage renal disease – permanent kidney failure), or those who have Lou Gehrig’s disease.
medicare
_______, or Title XIX, is a welfare program funded by state and federal dollars for people who have limited incomes and resources to cover the cost of health care. This is not insurance. It is a welfare program.
Medicaid
People that qualify for both Medicaid and Medicare are referred to as ____-_____
Dual-eligible
TF: Medicaid provides coverage for medical care and services that Medicare only partially covers, including nursing home and home health care.
True
_______ provides health insurance coverage to active duty and retired members of the uniformed services and their dependents.
TRICARE
TRICARE: _____ is managed care that provides comprehensive coverage, with fewer out-of-pocket costs
Prime
TRICARE: _____ is “fee for service” coverage that allows enrollees to receive medical care from any medical provider, but has higher out-of-pocket costs.
Standard
TRICARE: _____ allows enrollees to receive medical care through a PPO arrangement, which is TRICARE in-network with discounted cost sharing.
Extra
_____ ______ disability benefits are only available to covered workers who are fully insured at the time of disability
Social Security
TF: Disability income benefits are paid to the covered worker in the amount of the primary insurance amount (PIA) after a 6 month waiting period. Social Security disability benefits are only available prior to the age of 65.
False - 5 month waiting period
TF: Social Security does not pay partial disability or short-term disability benefits. The disability must be total and the following conditions must be met:
The covered worker cannot do the work they did prior to the disability;
The covered worker cannot do other work because of physical or mental conditions; and
The disability has already lasted or will last for at least 12 full months, or the disability is expected to result in death.
True
