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27 Cards in this Set
- Front
- Back
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Medicare originally consisted of what?? (2 parts)
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Part A: primarily for inpatient care
(in-hospital care, skilled nursing care, hospice, and home health care) Part B: ambulatory care (health care not involved with hospitalization) |
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What does part A cover?
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inpatient care
Covers in-hospital care, skilled nursing care, hospice, and home health care. Part A benefits are financed by Social Security taxes, require no premium payment by the beneficiary, and are automatic for those 65 and older. |
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Medicare (Part A) [if certain criterias are met] provides health care coverage without a premium cost, but.....
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it is not free health care!
(includes deductibles and co-insurance provisions) |
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What is the purpose of deductibles and coinsurance?
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Mechanisms designed to limit costs and to give greater responsibility for use of services to the insured
(insured will not likely go to a doctor if it is unnecessary because of what they have to pay) |
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What is the waiting period known as?
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The Blue Cross Equalizer
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What year is considered marking the start of modern health care?
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1929
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Who were the fortunate recipients of the first health insurance plan established?
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School teachers
-started by Justin Ford Kimball |
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What is the difference between Blue Cross and Blue Shield?
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Blue Cross: hospital and surgical coverage
Blue Shield: physician services coverage |
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What was the first major, national health insurance plan called?
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Blue cross
-evolved out of Justin Ford Kimball's plan (Baylor Plan) -late 1930s |
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Why were doctors fearful of the early Blue Shield insurance plans?
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concerned that non-medical people would tell them how to practice
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Medicare
(before any payment by Medicare is authorized) |
There are a considerable number of restrictions and requirements the patients must meet by Medicare Part A and Part B before any payment by Medicare is authorized
(Medicare can deny payments if they see something wasn't necessary during past history) |
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Medicare---Health insurance program for persons 65 and older...
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Regardless of income or wealth
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What is a deductible?
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-predetermined amount of money that a patient MUST pay before the insurance policy provides any benefits
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What is coinsurance?
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A % of the cost of each service that must be paid by the insured along with the insurance policy payment.
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What is a co-pay?
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A flat, pre-determined fee that must be paid for each type of service
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What year is the official beginning or birth of modern health insurance?
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1929
Justin Ford Kimball school teachers |
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What does Blue Cross cover?
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Hospital and Surgery coverage ONLY
Note: Over a period of time, Blue cross and Blue shield has merged as one Insurance in most of the states except few. |
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What does Blue Shield cover?
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Physician/PA services ONLY
Note: Over a period of time, Blue cross and Blue shield has merged as one Insurance in most of the states except few. |
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What was the first major, national health insurance plan called?
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blue cross: evolved out of Justin Ford Kimball's plan (Baylor plan)
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What is HIPAA?
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Health Insurance Portability and Accountability Act
-federal law that changed insurance rules including giving people the right to change jobs without fear of losing coverage -provisions regarding patient privacy |
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Medigap coverage?
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The private insurance that Medicare beneficiaries can purchase that covers the portion of the bill not paid by Medicare
(deductibles and copays) |
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What is AAPCC?
(Adjusted Average per Capita Cost) |
Federal calculation that determines how much Medicare pays a managed care company each month to cover Medicare beneficiaries living in a certain area
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Which of the following occupations is NOT a physician?
-ophthalmologist -osteopath -allopath -psychologist -psychiatrist |
-psychologist (they don't require going to medical school)
-you need to go to medical school to be considered a physician |
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Prior to the 1990's, little attention was paid to health, wellness, prevention, or treatment of chronic illness. What was the focus?
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focus was on cure and "sick care" rather than health care
-no system; everyone worked independently |
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What does accepting medicare assignment mean?
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Patient must pay deductible
Physician agrees to accept 80% of what medicare determines to be a reasonable fee. MUST bill the patient only for the balance (20% of the fee set by medicare) |
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Medicare does not pay for "custodial care." what must a physician or PA need to do in order to have Medicare patient covered for extended skilled nursing?
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Medicare patient must have been in an acute care hospital for at least 3 full days
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What does medicare NOT pay for?
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Custodial care
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