Building Blocks
A process by which an insurance company uses information about a plan members health status, personal and family health related behaviors to predict the member’s likelihood of experiencing specific illness or injuries.
The "Gatekeeper" is also known as?
A PCP (Primary Care Physician)
How many years/ quarters a Medicare member must satisfy before Part A be given free of charge?
10 years of 40 quarters
This is a payment model where each service is paid separately.
Fee For Service
Also known as the payer of last resort.
Medicaid
This is a pre-determined amount by the insurance company to the policy holder, which has to be born before the insurance company starts providing the coverage.
Deductibles
True
This branch of medicine is also concerned with the integration of developmental events proliferation, growth, and differentiation, and the psychological or behavioral activities of metabolism, growth and development, tissue function, sleep, digestion, respiration, excretion, mood, stress, lactation, movement, reproduction, and sensory perception caused by hormones.
Endocrinology
This is the part of Medicare that covers the member for any medical services - doctor visits, lab tests, outpatient hospital services among others.
Part B
An individual whose income level is below the _______ is eligible for Medicaid.
Federal Poverty Line
The timely filing limit set by Emblem Health to providers file claims is?
365 days or 1 year from the date of service
This type of plan gives the member the freedom to go to specialists without PCPs referral as PCP contact is not mandatory. However, the member can only go to in network specialists.
EPO (Exclusive Provider Organization)
Is the branch of medicine concerned with the study of the cause, prognosis, treatment, and prevention of diseases related to blood. It involves treating diseases that affect the production of blood and its components, such as blood cells, hemoglobin, blood proteins, bone marrow, platelets, blood vessels, spleen, and the mechanism of coagulation.
Hematology
This is a special kind of prior approval that health plan members must obtain form their PCP before seeing a specialist.
Referral
True or False. A primary subscriber who has Medicaid can add his/her children as dependents.
False
These are professionals in the insurance company, who review's the HRA and comes up which the benefit plan document.
Underwriter
Managed Care Plans are also called as?
Network Plans
COBRA stands for?
Consolidated Omnibus Budget Reconciliation Act
Medicare Part C is also known as?
Medicare Advantage
True or False. A primary subscriber who has Medicare can add his/her spouse as a dependent.
False
These are insurance professionals who perform the mathematical analysis necessary for setting insurance premium rates.
Actuaries
POS (Point of Service)
This is the amount paid for a medical service in a geographic area based on what providers in the area normally charge for the same or similar medical service. This rule is commonly followed by health insurance companies as at times, used to determine the allowed amount.
Usual and Customary Rate
With this type of plan, the patient may need to pay more premium for getting coverage for preventive care services.
Fee For Service or Traditional Indemnity Plan or Old Fashion Plan
This is a state program that allows certain individuals to qualify for Medicaid coverage even though they receive income in excess of eligibility requirements.
Medicaid Spend-Down