Self insured plans - Study guides, Class notes & Summaries

What Act shaped how commercial insurance carriers approached the concepts of paying for medical care? - ANSWER-HMO Act of 1973 ACA - ANSWER-Affordable Care Act HMO (Health Maintenance Organization) - ANSWER-The organization is both the insurer and provider of a set of defined services. Patients within this network must use an in-network provider for their services to be covered. Capitation Payment - ANSWER-part of prospective payment in which healthcare providers receive fixed monthly p...

CEBS - GBA 1 AND 2- PRACTICE EXAM QUESTIONS AND ANSWERS 2024 WITH COMPLETE SOLUTION Which of the following statements correctly describes minimum requirements that group benefit plans typically must meet in order to be prospectively rated on contract renewal? Ans- The more unpredictable the event that will trigger a claim, the larger the minimum group size and premium requirements Which of the following statements correctly describes the term graduation as it applies to mortality tables?...

Medical billing and coding latest version graded A+ Medical Insurance Financial plan (the payer) that covers the cost of hospital and medical care Policyholder Person who buys an insurance plan; the insured, subscriber, or guarantor Health Plan Individual or group plan that provides or pays for the cost of medical care Benefits What a health plan pays for services covered in an insurance policy; listed in the schedule of benefits. Medical Necessity Reasonable services of prov...

Healthcare Financing Correct Ans the system that a society uses to pay for healthcare services. USA does not have a single-payer system like Europe and Canada We have insurance plans which both patients and providers benefit from. (Patient gets a discount while Provider gets reimbursed). Financing increase the demand for service and the supply of professionals. Insurance (Insurer or Underwriter) Correct Ans Protects the insured against risk. Companies do not want to lose money so try to ...

CRCR EXAM WITH CORRECT CHOICES, CERTIFIED AND VERRIFIED What are collection agency fees based on? - CORRECT ANSWER-A percentage of dollars collected Self-funded benefit plans may choose to coordinate benefits using the gender rule or what other rule? - CORRECT ANSWER-Birthday In what type of payment methodology is a lump sum or bundled payment negotiated between the payer and some or all providers? - CORRECT ANSWER-Case rates What customer service improvements might improve the patie...

Interim Coverage - short-term policies that can be purchased on an interim basis when in between jobs or waiting for a new policy to start how is health insurance calculated? - Interest,expense,types of benefits and morbidity, or the expected incidence of sickness or disability within given age group during the given period of time. Health insurance - broad field of insurance plans that provide protection against the financial consequences of illness, accidents, injury and disability What ...

According to the RAND Health Insurance Experiment, which variable has the greatest power in explaining health expenditures? A.) Welfare eligibility B.) Prior utilization C.) Physical health (based on self-reported measures) D.) General health (based on self-reported measures) E.) Mental health (based on self-reported measures) - ANSWERB.) Prior utilization A provision in some group life insurance plans that provides for the payment of all or part of the death benefit in the event...

An organization outside the members of a self-insurance group which, for a fee, processes claims, completes benefits paperwork and often analyzes claims information is known as the: 1) primary administrator (PA). 2) second-party administrator (SPA) 3) third party administrator (TPA) 4) administrator. -Correct Answer According to the NAIC Model Health Insurance Policy Provisions, under the _________________________ provision, the insurer is prohibited from denying a claim on the basis...

Indiana Navigator Exam Questions and Answers Already Passed Auto Assignment the process by which an individual who does not select a Hoosier Healthwise (HHW) or HIP Managed Care Entity (MCE) at the time of the HHW or HIP application, or within 14 days of the submission of the application, is automatically assigned to a Managed Care Entity (MCE) Certificate of Coverage a list of benefits, services, cost sharing, exclusions, and limits applied by a particular health insurance policy. ...

ACA requirements for insurers - ANSWER(a) Insurers may no longer exclude members based on preexisting conditions. (b) Insurers may not place annual or lifetime caps on coverage. (c) All fully insured products must comply with a medical loss ratio (MLR) requirement. It mandates that health insurance issuers in the individual and small group markets and in the large group market spend at least 80% and 85% of premiums, respectively, on health care activities (as opposed to administrative func...