CCM Financial Management & Reimbursement Flashcards

Which federal program provides health coverage primarily to individuals aged 65 and older, directly impacting reimbursement decisions in care management?

Answer: Medicare

Medicare is the federal health insurance program for individuals aged 65 and older, and understanding its reimbursement structures is essential for care managers.

A care manager is helping a client navigate out-of-pocket costs. Which term describes the fixed amount a patient pays for a covered health care service after meeting their deductible?

Answer: Copayment

A copayment is a fixed dollar amount paid by the patient for a specific covered service, separate from the deductible.

Which reimbursement model pays providers a set amount per patient per month regardless of services rendered, incentivizing preventive care?

Answer: Capitation

Capitation pays a fixed monthly rate per enrolled patient, encouraging cost-effective and preventive care delivery.

A CCM is reviewing a client's Explanation of Benefits (EOB). What is the primary purpose of this document?

Answer: It explains what the insurance paid and what the patient owes

An EOB is a statement from the insurer detailing what was billed, what the plan covered, and what the patient is responsible for paying.

Which term refers to the negotiated maximum amount a health insurance plan will pay for a covered service from an in-network provider?

Answer: Allowable amount

The allowable amount is the maximum negotiated rate the insurer will pay for a service, with the patient responsible for their share of that amount.

Under the Affordable Care Act (ACA), what is the term for the annual cap on out-of-pocket expenses a patient must pay for covered in-network services?

Answer: Out-of-pocket maximum

The out-of-pocket maximum is the most a patient will pay in a year for covered services; after reaching it, the insurer covers 100% of covered costs.