Blue Cross Blue Shield -BSBS - Chapter 13 Exam Study Guide with Complete Solutions

Blue Cross Blue Shield -BSBS - Chapter 13 Exam Study Guide with Complete Solutions policyholder - Answer️️ -Health insurance is a contract between a ________, one who purchases the contract insurance carrier - Answer️️ -one who provides the benefits plan or a goverment program developed to reimburse the policyholder of all or most medical expenses There are 3 ways an individual can obtain health insurance - Answer️️ -Group Insurance, Personal Insurance, and Pre-paid health Plan Group Insurance - Answer️️ -when a group of employees and their dependents are insured under one group policy issued to the employer. Generally, the employer pays the premium or a portion of the premium and the employee pays the difference. Personal Insurance - Answer️️ -an insurance plan issued to an individual. Premium rates are usually higher than group rates and service availbility is lessened with this type of coverage. Pre-paid Health Plan - Answer️️ -pre-determined set of benefits covered under one set annual fee Indemnity Insurance - Answer️️ -also known as fee-for service. Under this plan, the services that are paid for are listed in the policy and payments are based on the fees physicians charge for the service. There are no restrictions as to the physician or ©SOPHIABENNETT EXAM SOLUTIONS_2024/2025 Monday, September 2, 2024 12:59 PM Page | 2 hospital the beneficiaries may use and pre-approval of medical visits is not required. Each year, the beneficiary must meet a deductible, after which, the benefit may cover fall all or part of the charge. Usually, a coinsurance for each service applies ( a 80-20 coverage means that the insurance carrier pays 80% and the policyholder pays 20% of each dollar of medical care provided.) Health Maintenance Organization (HMO) - Answer️️ -is a managed care benefits plan that provides a wide range of medical services to individuals that have been enrolled into the program. It is generally the least costly but at the same time also the most restrictive. This plan uses a gatekeeper physician (primary care physician) whom the beneficiary is required to visit initially for any case. If the beneficiary goes to another physician without the prior approval of the primary care physician, the beneficiary will be responsible for all costs for the case. Physician-hospital organization is when physicians, hospitals and other health care providers contract with one of more HMO's or directly with employers to provide care. Preferred Provider Organization (PPO) - Answer️️ -is basically the same as HMO in the sense that the health care provider enters into contract withthe MCOs to render services to the beneficiaries. There is no gatekeeper-physician and beneficiaries choose the provider from whom to seek services so long as the provider is within the network. If the beneficiary chooses to seek care from a provider not within the network, that beneficiary will shoulder all cost of the services. Point-of-Service plan (POS) - Answer️️ -is a managed care plan that gives beneficiaries the option whom to see for services. If the beneficiary goes to see s physician within the network,s/he will receive benefits similar to an HMO. Bit if the ©SOPHIABENNETT EXAM SOLUTIONS_2024/2025 Monday, September 2, 2024 12:59 PM Page | 3 beneficiary chooses to see a physician from out of network, the POS will still pay for the services but at a rate significantly lower than that of in network physician and the difference between the POS payment and the billed charges shall be shouldered by the beneficiary. Preferred Provider plan - Answer️️ -is the type of plan a patient may have where they can see providers outside their plan. The patient is responsible to pay the higher portion of the fee. Fee Schedule - Answer️️ -The Usual, Customary, and Reasonable Usual, Customary, and Reasonable (UCR) - Answer️️ -method is used mostly in reference to fee-for-service reimbursement. To arrive at a payment amount for a claim 1. Usual - Answer️️ -The physician's most frequent char