Term
| What are Preventive Services? |
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Definition
| Medical services identified by the ACA that insurance companies must Covered in Full if specific diagnosis, age, and other criteria are met. |
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Term
| How do you determine if a service is Covered in Full as a Preventive Service under the ACA Mandate? |
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Definition
| You will use the Preventive Services Grid *PPACA** |
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Term
| What types of codes will you use while researching the PPACA Grid? |
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Definition
| Procedure Codes *CPT*, Modifiers & Diagnosis Codes |
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Term
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Definition
| These services include medical screenings and checkups. They help prevent health problems before you have any symptoms. They do not include tests or services to monitor or manage a condition or disease once it has been diagnosed. |
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Term
| Define Diagnostic Services |
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Definition
| These services include medical screenings and checkups that are focused on diagnosing an illness or injury. Diagnostic medical care involves treating or diagnosing a problem you’re having by monitoring existing problems, checking out new symptoms or following up on abnormal test results. |
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Term
| Excluded Products from the Preventive Services: |
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Definition
• Medicare Supplement
• Child Health Plus
• Medicaid
• Dental Only
• Drug Only
◘ Modifier 33 must be used for specific services to indicate that the service was rendered under the Preventive Services ACA Mandate |
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Term
| Preventive Services For Women |
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Definition
• Breast Pumps / Supplies
• Contraceptives |
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Term
| Maternity benefits are complicated because they involve many variables, including: |
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Definition
• Multiple types of benefits
• Different levels of care / lengths of stay
• More than one patient (Mother & the Child)
• Patients overall health (well vs sick, vaginal births vs c-section, maternity vs medical)
• Potentially more than one medical policy |
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Term
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Definition
• Prenatal Care
• When admitted to the hospital for delivery
• Following delivery |
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Term
TRUE or FALSE:
Regardless if the newborn is added to the policy as a permanent member or not. The law requires TEMPORARY coverage for the newborn |
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Definition
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Term
TRUE or FALSE:
If a baby is diagnosed as “sick”, a medical benefit would apply |
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Definition
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Term
| Policies Excluded from the Newborn Mandate: |
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Definition
• Medicaid and Family Health Plus (Under Medicaid a newborn is automatically enrolled from moment of birth)
• Child Health Plus
• Essential Plan
• Federal Employees Health Benefit Plans (FEP)
• Self-insured (ASO/ASC) Groups, UNLESS the self-insured (ASO/ASC) Group opts to mirror the mandated benefit. Article 47 groups are required to follow state mandates and are not exclusions. Otherwise, the Federal Mandate applies |
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Term
TRUE or FALSE:
"Therapies" refers to physical *PT*, occupational *OT*, speech therapy *ST*, as well as Comprehensive Outpatient Rehabilitation Facility *CORF* and Early Intervention |
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Definition
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Term
| What are the following services we must consider for Mom's care when quoting Maternity? |
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Definition
| Prenatal Care, Admission to the Hospital for Delivery, Postnatal Care |
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Term
| A few of the covered services under the Infertility Mandate |
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Definition
| Hysterosalpingogram, Sono-hysterogram, Laparoscopy |
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Term
TRUE or FALSE:
Infertility testing and treatment are mandated as "covered", but not "covered in full" |
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Definition
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Term
TRUE or FALSE:
If the primary benefit indicates drugs are inclusive to the primary - there is no need to search for an additional benefit. Advocates should quote the primary benefit. |
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Definition
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Term
| Number of unites approved for a Medical Specialty Drug requires confirmation through what database? |
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Definition
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Term
| A Skilled Nursing Facility *SNF* is more commonly known as what? |
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Definition
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Term
| Skilled Nursing Facility *SNF* care occurs as the following: (short term, long term, or both?) |
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Definition
| BOTH: Short Term (following a surgery, illness, or injury) and Long Term ("Residential Care") |
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Term
TRUE or FALSE:
If a member does NOT exhaust their benefits for SNF and is admitted again before 60 days have passed, they may access any remaining benefit |
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Definition
FALSE
(If a member does not exhaust their benefit allocation, and is again admitted before 60 days have passed - they may access any remaining benefit.) |
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Definition
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