Coordination of Benefits
Maria was laid off from her job in March and elected COBRA coverage through her former employer. In May, she started a new job and enrolled in her new employer’s health plan. She has not canceled COBRA yet.
Which plan is primary?
New employer’s active group plan
What type of network benefits does OMNIA product has?
OMNIA only has in-network benefits.
Name 7 PHI information identifiers.
Names, dates, phone#, geographic data, fax#, SSN#, email addresses, medical records, account#, health plan beneficiary, license#, serial#, IP addresses, web URLs, full face photos, biometric identifiers, certificate# or any other unique identifier.
Who is an eligible subscriber?
An individual must be a resident of New Jersey, must not be covered or eligible to be covered under Medicare, must not be covered under another individual plan or group plan unless that plan is being replaced, must make a valid election during an enrollment period
What does Medicare cover?
Mention all parts and what they cover.
Part A – Hospital Insurance
Part B – Medical Insurance
Part C – Medicare Advantage Plan
Part D – Prescription Drug Coverage
Carlos retired last year and kept retiree medical coverage through his former employer. His spouse, Elena, is still actively working and covers Carlos on her employer’s group plan.
Which plan is primary?
Elena’s active employer plan
Referrals are required but authorizations aren't on any of the OMNIA products.
True or False?
False.
Referrals are not required on any of the OMNIA products. And authorizations are required for certain services.
Reduces health care fraud and abuse.
Mandates industry-wide standards for health care information on electronic billing and other processes.
Requires the protection and confidential handling of protected health information.
A spouse who is separated from the policyholder may remain on the contract. They are considered eligible, because a separated spouse is still considered legally married.
True or False?
True
What is EOB and EOP?
Give me the acronyms and the description of them.
* Medical Explanation of Benefits (EOB): Provided to subscribers and delivers the details of how the claim processed.
*Explanation of Payment (EOP): Provided to providers and delivers the details of how the claim processed.
Liam is covered under his mother’s employer-sponsored plan. His mother recently married Liam’s stepfather, who also added Liam to his employer plan. All adults live together and there is no divorce or custody agreement involved.
Which plan is primary?
Depends on whose birthday falls first in the calendar year
Explain how the Deductible Tier 1 and Deductible Tier 2 works.
The OMNIA Tier 1 deductible accumulates to Tier 2. Tier 2 does not accumulate to OMNIA Tier 1.
What are the components of HIPAA?
Privacy, Transactions and Code Sets, Security and National Identifiers.
What Enrollment periods can an individual use to elect coverage or change plan?
Annual Open Enrollment Period (OEP) or Special Enrollment Period (SEP)
Using Medicare rules, when is long-term nursing care covered?
Long-term nursing care (i.e.: nursing home coverage) is not covered by Medicare.
Samantha is 62 and receives Medicare due to disability. She works full‑time for a company with 15 employees and is enrolled in the employer’s group health plan.
Which plan is primary?
Medicare
Name some of the general benefits that the OMNIA plan covers.
Preventive Services, Prescription Coverage, Vision Coverage and Hearing Services.
What is the minimum necessary rule?
It is a HIPAA privacy rule that state that only those who need to see PHI to do their jobs should get to see it, and unless you have a specific need for the information, access must be restricted.
List 3 reasons that may trigger a Special Enrollment Period.
Loss of qualifying health coverage, Change in household size, Change in primary place of living, Change in eligibility for Marketplace coverage or help paying for coverage, Enrollment or plan error, Other qualifying changes
What are the 10-steps End-to-End Insurance Process?
Eligibility, Enrollment, Billing, Covered Benefits, Provider Selection, Utilization Management, Services Rendered, Claims, Subscriber Liability and Case Management.
Ethan has health insurance through his parent’s Horizon BCBSNJ plan. His college also provides a student health plan that covers routine office visits, prescriptions, and hospitalizations (not just accidental injury).
Which plan is primary?
Parent’s Horizon BCBSNJ plan
What is the difference between a True Family Deductible and an Aggregate Deductible?
* True Family: Full deductible amount must be met before Horizon will process coinsurance or copays.
*Aggregate: Once a member's individual deductible is met, their claims will begin to pay at the applicable coinsurance/copay.
Name 4 Non-Routine Disclosures.
When required by law, For public health activities/concerns, Regarding victims of abuse, neglect, or domestic violence, For health oversight activities, For judicial and administrative procedures, For law enforcement purposes, For cause of death or identification of a deceased individual, To avert a serious threat to health or safety, For workers compensation purposes.
What is an Initial Coverage Election Period?
It's only for people newly eligible for Medicare, the election period:
Begins three months before the month the person turns age 65 and ends three months after the month the person turns age 65.
What type of plan have premiums are higher than other types of plans and freedom to receive in or out of network care.
Preferred Provider Organization (PPO Plan)