1-7. Health Care Plans Flashcards
1
Q
- Health Care Plans
1. Some health care plans are owned and operated by organizations that are not insurance companies.
A
True
1.
2
Q
- Health Care Plans
2. Managed care programs can lower costs by contracting with a limited number of providers.
A
True
2.
3
Q
- Health Care Plans
3. The deductible in a health care plan refers to the dollar amount that will be paid by the insurer.
A
False
- Rationale: The deductible is the financial responsibility of the insured.
4
Q
- Health Care Plans
- “Indemnity” refers to an insurance philosophy that a policyholder should be made financially “whole” after suffering a loss.
A
True
4.
5
Q
- Health Care Plans
- In a “per cause” deductible policy, the insured pays a deductible for each separate illness, regardless of any amount previously paid for other illnesses.
A
True
5.
6
Q
- Health Care Plans
- Medical Savings Accounts (MSAs) are similar to Individual Retirement Accounts (IRAs) in that money is not available without penalty until age 59½.
A
False
- Rationale: Unlike IRA deposits, MSA deposits can be withdrawn without penalty to pay for unreimbursed medical expenses. As is the case with IRAs, deposits are (within statute) deductible in the year invested.
7
Q
- Health Care Plans
7. There are currently 20 standard Medigap plans.
A
False
- Rationale: There are currently 14 standard Medicare supplement plans (also known as Medigap plans). Although new plans E, H, I and J cannot be sold, existing plans can continue to be used. Plans K and L were added several years ago, and plans M and N are included in 2010.
8
Q
- Health Care Plans
- The precertification provisions in health care plans stipulate that the plan provider must approve certain medical procedures before the plan will cover the procedure.
A
True
8.
9
Q
- Health Care Plans
- UCR tables show what is usual, customary, and reasonable for medical services and are identical for all insurance companies.
A
False
- Rationale: UCR tables may vary by insurance company and by geographic region.
10
Q
- Health Care Plans
- If there is conflicting information between a group health care plan’s summary of benefits (given to employees) and its comprehensive contract, the summary of benefits holds precedence.
A
False
- Rationale: The comprehensive contract governs in cases where there are conflicts with the summary of benefits sheet given to employees. In many cases, however, employees have won court cases in similar disputes.
11
Q
- Health Care Plans
- Preexisting conditions clauses will, for the most part, no longer be in use with the passage of the Patient Protection and Affordability Act (PPACA) 2010.
A
True
- Preexisting conditions clauses will, for the most part, no longer be in use with the passage of the Patient Protection and Affordability Act (PPACA) 2010.
12
Q
- Health Care Plans
12. Utilization review procedures may include second opinions.
A
True
- Utilization review procedures may include second opinions.
13
Q
- Health Care Plans
13. The higher the deductible paid by the insured, the higher the premium.
A
False
- Rationale: The higher the deductible paid by the insured, the lower the premium.
14
Q
- Health Care Plans
14. The lifetime benefit that insurers will pay for a covered individual is commonly $1 million.
A
False
- Rationale: Maximum policy limits have been removed by enactment of the Patient Protection and Affordability Act (PPACA) 2010.
15
Q
- Health Care Plans
- Insurers employ coordination of benefits clauses to enable insureds to collect more than 100% of their financial loss.
A
False
- Rationale: Coordination of benefits clauses reinforce the concept of indemnity. If an insured is covered by two policies, these clauses will keep the insured from being reimbursed an amount exceeding his or her original payment.
