Benefits
Insurance Terminologies
Insurance Types
CMS Facts
General Knowledge
100

..... is the flat amount the member pays at the time of a medical service or to receive a medication.

What is A Copay

100

The point at which the patient leaves the hospital and either returns home or is transferred to another facility such as one for rehabilitation or to a nursing home. This may also involves the medical instructions that the patient will need to fully recover.

What is Discharge (Discharge Date) 

100

An insurance paid by employers when an employee gets injured at work.

What is Workers Compensation 

100

The agency within the Department of Health and Human Services that is responsible for the administration of the Medicare program, as well as the federal participation in the state Medicaid program.

What is Centers for Medicare and Medicaid Services (CMS) 

100

Notification to an insurance company that payment of an amount if due under the terms of a policy.

What is A Claim 

200

...... is a fixed amount of money the member has to pay before most, if not all, of the policy's benefits can be enjoyed.

What is A Deductible

200

The actual dollar amount charged by a physician or other provider for medical services rendered.

What is Charge Amount 

200

This pays out money called a death benefit to a designated beneficiary when you die. You can name people, companies, or trusts as beneficiaries, and you can have more than one beneficiary who will split your death benefit in accordance with your instructions.

What Is Life Insurance

200

These Criteria need to be met in order to be on Medicare

What is Person age 65 or older, Disabled persons, and person with End Stage Renal Disease (ESRD) or otherwise known as Permanent Kidney failure

200

HIPPA is also known as the ___________ Act.

What is The Kennedy-Kassenbaum Act

300

....... expenses are what the member pays for health-related services above and beyond their monthly premium. Depending on the health plan, these expenses may include an annual deductible, coinsurance, and copayments for doctor visits and prescription drugs

What is An Out- Of - Pocket

300

A method of reimbursement to providers for each treatment or procedure performed.  Payment may be made by an insurance company, patient, or government program such as Medicare or Medicaid.

What is Fee for Service 

300

A type of insurance that offers more than health insurance and is financed by premiums.

What is Commercial Insurance

300

A claim form used by professionals to bill for services.  Required by Medicare and generally used by private insurance companies and managed care plans

What is The CMS-1500

300

The act of manipulating people into performing actions or divulging confidential information, rather than by breaking in or using technical hacking techniques; essentially a fancier, more technical way of lying.

What is Social Engineering 

400

This is the highest or total amount a health insurance company requires a member/subscriber to pay towards the cost of their health care.


Typically, after the member’s responsibilities are met for the benefit year, the insurance company will pay for 100% of all covered medical services.

What is the Maximum Out- Of- Pocket

400

Method of payment in which the provider is given a fixed dollar amount for each patient served, regardless of the actual number or nature of services rendered. It is also is expressed as a "per member per month" amount.

What is Capitation 

400

This is intended to pay for the costs of medical care. Many people get this type of insurance through employers who subsidize premiums, meaning the employer pays the bulk of your premium, and you chip in a little with each paycheck.

What is Health Insurance

400

A joint Federal and state program that helps with medical costs for some people with low income and limited resources.

What is Medicaid

400

Licensed by the government to provide medical care, services, goods, and supplies to patients.

What is A Provider 

500

These are services or supplies a health plan agrees to cover. Covered benefits and services differ from plan to plan. There are still costs that aren’t covered by health plans and are payable by the member, such as:

–    Copayment

–    Deductible

–    Coinsurance

–    Limitations/Maximums

–    Non- covered Services


What is Benefits

500

The practice of a provider billing a patient for all charges not paid for by the insurance plan.  (i.e. charges above the plan’s fee schedule).  Most plans prohibit this except for allowed copay, coinsurance, and deductibles.

What is Balance Billing

500

A US federal government program that provides health insurance to people over 65 primarily, whatever their income; and serves younger disabled people and dialysis patients

What is Medicare 

500

Comprises of Part A, Part B and or Part D and is usually offered by private insurance carriers such Aetna Human, Cigna ETC

What is Medicare Advantage Plans

500

An organization or agency, certified by Medicare whose is primarily engaged in providing pain relief to terminally ill people and their families

What is Hospice 

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