CBCS Payer Types and Policies 2

Question 1

What is TRICARE and who is eligible for it?

Accepted Answer

The health care program for active-duty service members, retirees, and their families through the Department of Defense

Answer

A federal health program for low-income families

Answer

A supplemental insurance plan for Medicare beneficiaries

Answer

A state-administered insurance program for government employees

Question 2

What is a Medicare Administrative Contractor (MAC)?

Accepted Answer

A private company contracted by CMS to process Medicare fee-for-service claims in a specific geographic jurisdiction

Answer

A private company that designs Medicare benefit plans

Answer

A Medicare-approved company that provides managed care plans

Answer

A contractor that audits Medicare Advantage organizations

Question 3

What is the Federal Employees Health Benefits (FEHB) Program?

Accepted Answer

The health benefits program for federal civilian employees, retirees, and their dependents, offering a choice of health plans

Answer

A health plan exclusively for members of Congress

Answer

A government-subsidized program for unemployed federal workers

Answer

Medicare coverage for federal government retirees

Question 4

What is a self-funded (self-insured) employer health plan?

Accepted Answer

An employer that assumes financial responsibility for employee health claims rather than paying premiums to an insurance company; typically administered by a TPA

Answer

An employer that purchases a standard insurance policy from an insurer

Answer

A small employer that qualifies for a government subsidy to fund health benefits

Answer

An employer that provides health benefits funded entirely by employee payroll deductions

Question 5

What is Workers' Compensation insurance, and how does billing differ from standard health insurance?

Accepted Answer

Insurance that covers medical treatment and lost wages for employees injured on the job or who develop work-related illnesses; billing uses separate forms and diagnosis coding specific to the injury

Answer

Insurance for employers to cover their liability if an employee injures a patient

Answer

Insurance that employees purchase themselves to cover job-related injuries

Answer

A federal insurance program for all injury-related medical care

Question 6

What is a National Coverage Determination (NCD)?

Accepted Answer

A CMS policy determining whether a service, item, or procedure is covered nationally under Medicare, binding on all MACs and Medicare Advantage plans

Answer

A state-level insurance mandate requiring coverage of specific conditions

Answer

A determination made by a provider as to whether a service is medically necessary

Answer

A coverage decision made by a commercial insurer for its subscriber population