Insurance Flashcards
(97 cards)
Annual Healthcare Expenditures?
- 5 Trillion
17. 9% of GDP
Projected Growth in National Health Expenditures?
6 Trillion by 2027
Financial Loss due to fraud in healthcare?
3% (most conservative)
~$300 billion
When was Medicare created?
1965 for individuals over 65
When did Medicare expand to ESRD?
1972
What does Medicare Part A cover?
Inpatient hospital and skilled nursing and hospice
What does Medicare Part B cover?
optional medical insurance (requires premium), covering doctors’ visits, outpatient medical and surgical services and supplies, diagnostic tests, and DME
What does Medicare Part C (Advantage) cover?
Established in 1997 to allows Medicare beneficiaries to join privately operated MCO’s.
What does Medicare Part D cover?
Established in 2003 to cover prescription drugs for eligible enrollees.
When was Medicaid established?
1965 to cover certain low-income families, as well as certain low income, blind, and disabled individuals. Medicaid is a joint federal/state program.
When was CHIP established?
1997 and provides federal matching funds to states to
provide health care coverage to children of families with incomes that are too high to qualify for Medicaid, but who can’t afford private health insurance coverage.
What is TRICARE?
Regionally managed health care program for active duty,guard, reserves, and retired members of the uniformed services and their families. It is managed by the Defense Health Agency
Federal agencies?
CMS, HHS-OIG (LEIE), NPDB, DOJ
State agencies?
Medicaid Program Integrity Units (MPIU), Medicaid Fraud Control Units (MFCU), Medical Board, Nursing Board, Licensing Boards, OAG, DOI
Independent Organizations?
NAIC
JACOH
NCQA
What does ERISA stand for? When was ERISA established?
Employee Retirement Income Security Act of 1974
Health insurance coverage that you purchase on your own, on an individual or family basis, as opposed to through an employer.
Individual Health Insurance
This insurance is usually based on an employer - employee relationship but may be offered to groups who join together out of a common interest, such as trade associations or unions.
Group Health Insurance
Insurance plan where members can see any health care provider in the network, including specialists, without a referral.
PPO
Insurance plan where an entire network of health care providers agrees to offer you its services. Members have to select a primary care provider (PCP) who coordinates all of your health services and care.
HMO
Insurance plan where members have access to all of the health care providers within the EPO network, including specialists. Whereas PPO plans may offer some coverage outside of the network, EPO plans typically will not.
Exclusive Provider Organization (EPO) plans
Hybrid of HMOs and PPOs. Members typically designate a primary care physician for regular check-ups and referrals. Members can also use out-of-network providers and pay more out of pocket including a copayment and deductible.
Point of Service (POS) Plans
Requires any employer with 20 or more employees to extend Group Health coverage to terminated employees and their families for up to a period of 36 months after a qualifying event.
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requirements
When was HIPAA established?
1996
