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Life and Health > CH 11 Medical Plans > Flashcards

CH 11 Medical Plans Flashcards

1
Q

Why do HMOs encourage members to get regular check ups?

A

To help catch health problems early when treatment has the greatest chance for success (i.e. preventative care)

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2
Q

What is the main difference between coinsurance and copay?

A

Co-pay is a set dollar amount; coinsurance is a percentage of the expenses

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3
Q

What is the role of the gatekeeper in an HMO plan?

A

To control costs for the services of specialists

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4
Q

How can an HMO member see a specialist?

A

Referral by the primary care physician

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5
Q

What are usual/reasonable and customary charges based on?

A

Average charge for a given procedure in the specific geographic area

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6
Q

What are the two types of flexible spending accounts?

A
  • Healthcare accounts

* Dependent care accounts

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7
Q

In what type of health plans are providers paid for services in advance, regardless of the services provided?

A

Prepaid plans

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8
Q

What is a fee for service health plan?

A

Under a fee for service plan, providers receive payments for each service provided

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9
Q

What are the tax implications for contributions to a health savings account by the individual insured?

A

Contributions are tax deductible

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10
Q

What is the purpose of the coinsurance provision in health insurance policies?

A

To prevent overutilization of the policy benefits

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11
Q

What type of health insurance plans cover all accidents and sicknesses that are not specifically excluded in the policy?

A

Comprehensive plans

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12
Q

What types of injuries and services would be excluded from major medical coverage?

A
  • Injuries caused by war
  • Intentionally self-inflicted injuries
  • Injuries covered by workers compensation
  • Regular dental/vision/hearing care
  • Custodial care
  • Elective cosmetic surgery
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13
Q

Who chooses a primary care physician in an HMO plan?

A

The individual member

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14
Q

Under what type of care do insurers negotiate contracts with healthcare providers to allow subscribers access to healthcare services at a favorable cost?

A

Preferred Provider Organization (PPO)

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15
Q

Can an insured who belongs to a POS plan use an out of network physician?

A

Yes, but the co-pays and deductibles may be higher

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16
Q

What provision provides for the sharing of expenses between the insured and the insurance company?

A

Coinsurance

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17
Q

What are the five basic characteristics of managed care plans?

A
  • Controlled access to providers
  • Comprehensive case management
  • Preventative care
  • Risk sharing
  • High quality care
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18
Q

What is the purpose of managed care health insurance plans?

A

To control health insurance claims expenses

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19
Q

How are HMO territories typically divided?

A

Geographic areas

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20
Q

What are the three types of basic medical expense insurance?

A
  • Hospital
  • Surgical
  • Medical
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21
Q

What is the main principle of an HMO plan?

A

Preventative care

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22
Q

When are newborns covered in individual health insurance policies?

A

From the moment of birth

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23
Q

A new employee who meets HIPAA eligibility requirements must be issued health coverage on what basis?

A) Nondiscriminatory
B) Indemnity
C) Guaranteed
D) Noncancellable

A

Guaranteed.

24
Q

On a major medical insurance policy, the amount that an insured must pay on a claim before the insurer will pay is known as

A) Copayment
B) Inside limit
C) Coinsurance
D) Deductible

A

Deductible

25
Q

Which of the following health care plans would most likely provide the insured/subscriber with comprehensive health care coverage?

A) Medical-surgical expense plan
B) Basic medical expense plan
C) Health Maintenance Organization plan (HMO)
D) Group dental insurance plan

A

Health Maintenance Organization plan (HMO).

26
Q

An applicant has a history of heart disease in his family, so he would likely buy a health insurance policy that strictly covers heart disease. What type of policy is this?

A) Scheduled benefit coverage
B) Dread disease coverage
C) Single indemnity protection
D) Term health coverage

A

Dread disease coverage.

27
Q

All of the following are ways in which a Major Medical policy premium is determined EXCEPT

A) The stop-loss amount
B) The average age of the group
C) The amount of the deductible
D) The coinsurance percentage

A

The average age of the group.

28
Q

In a POS plan, benefits for covered services when self-referring (without having your primary care physician arrange for the service) are generally

A) The same cost
B) Self-referral is not allowed
C) More expensive
D) Less expensive

A

More expensive.

29
Q

What is the main difference between coinsurance and copayments?

A) With copayments, the insured pays all of the cost
B) With coinsurance, the insurer pays all of the cost
C) Coinsurance is a set dollar amount
D) Copayment is a set dollar amount

A

Copayment is a set dollar amount.

30
Q

Which of the following answers does NOT describe the principal goal of a Preferred Provider Organization (PPO)?

A) Provide medical services only from physicians in the network
B) Provide the subscriber a choice of physicians
C) Provide the subscriber a choice of hospitals
D) Provide medical services at a reduced cost

A

Provide medical services only from physicians in the network.

31
Q

After a brief emergency room visit, an insured discovered that his plan required a larger copayment for an out-of-network provider than for a local, in-network provider. Under the PPACA provisions, this is

A) Part of the plan’s benefit schedule
B) Not permitted
C) Counted as part of the insured’s annual deductible
D) Reasonable and customary

A

Not permitted.

32
Q

An insured’s health claim internal appeal was denied. The insure must do all of the following EXCEPT

A) Complete the appeal in 60 days after service was received
B) Notify the insured how to obtain an outside review
C) Offer a payment plan
D) Notify the insured about the decision in writing

A

Offer a payment plan.

33
Q

HIPAA applies to groups of

A) At least 100
B) More than 2, fewer than 50
C) 2 or more
D) At least 10

A

2 or more.

34
Q

Fred and Jody are covered under a group health insurance plan at his place of employment. When Jody gave birth to their first child, what must he do in order to have coverage for their child?

A) Notify the insurer on the anniversary date of the plan
B) Notify the employer within 10 days
C) Notify the insurer immediately and provide proof of insurability
D) Notify the insurer within 31 days in order for coverage to continue without any evidence of insurability

A

Notify the insurer within 31 days in order for coverage to continue without any evidence of insurability.

35
Q

The Affordable Care Act requires all U.S. citizens and legal residents to have qualifying health care coverage. This is known as

A) Safe Harbor mandate
B) Special enrollment
C) The individual mandate
D) The Insurance Marketplace

A

The individual mandate.

36
Q

A man bought an individual health insurance policy for himself. Which of the following roles does he now legally have?

A) Broker
B) Subscriber only
C) Insured only
D) Both subscriber and insured

A

Both subscriber and insured.

37
Q

All of the following are characteristics of a Major Medical Expense policy EXCEPT

A) Coinsurance
B) Low maximum limits
C) Deductibles
D) Blanket coverage

A

Low maximum limits.

38
Q

To be eligible under HIPAA regulations, for how long should an individual converting to an individual health plan have been covered under the previous group plan?

A) 5 years
B) 12 months
C) 63 days
D) 18 months

A

18 months.

39
Q

In health insurance, if a doctor charges $50 more than what the insurance company considers usual, customary and reasonable, the extra cost

A) Must be covered by the insurer
B) Counts toward deductible
C) Counts toward coinsurance
D) Is not covered

A

Is not covered.

40
Q

Under the ACA, health insurance can no longer be underwritten based on which of the following factors?

A) The applicant’s family compensation
B) The applicant’s age
C) The applicant’s tobacco use
D) The applicant’s health condition

A

The applicant’s health condition.

41
Q

What is the maximum age for qualifying for a catastrophic plan?

A) 26
B) 30
C) 45
D) 62

A

30.

42
Q

Under HIPAA, which of the following is INCORRECT regarding eligibility requirements for conversion to an individual plan?

A) An individual who was previously covered by group health insurance for 6 months is eligible
B) An individual who has used up COBRA continuation coverage is eligible
C) An individual who doesn’t qualify for Medicare may be eligible
D) The gap of coverage for eligibility is a period of 63 days or less

A

An individual who was previously covered by group health insurance for 6 months is eligible.

43
Q

According to the PPACA rules, what percentage of health care costs will be covered under a bronze plan?

A) 10%
B) 30%
C) 40%
D) 60%

A

60%.

44
Q

Under which of the following organizations are the practicing providers compensated on a fee-for-service basis?

A) Open panel
B) PPO
C) HMO
D) BlueCross/Blue Shield

A

PPO.

45
Q

Bob purchased a policy to provide coverage on himself, his wife Linda, and their two children, John and Kristen. All of them would need to prove insurability EXCEPT

A) Any children born to them after the inception of the contract
B) Bob
C) Linda
D) John and Kristen

A

Any children born to them after the inception of the contract.

46
Q

A medical expense policy that establishes the amount of benefit paid based upon the prevailing charged which fall within the standard range of fess normally charged for a specific procedure by a doctor of similar training and experience in that geographical area is known as

A) Gatekeepers
B) Usual, customary, and reasonable
C) Relative-value schedule
D) Benefit schedule

A

Usual, customary, and reasonable.

47
Q

Which of the following is true of a PPO?

A) Claim forms are completed by members on each claim
B) No copayment fees are involved
C) Its goal is to channel patients to providers that discount services
D) The most common type of PPO is the staff model

A

Its goal is to channel patients to providers that discount services.

48
Q

A medical insurance plan in which the health care provider is paid a regular fixed amount for providing care to the insured and does not receive additional amounts of compensation dependent upon the procedure performed is called

A) Indemnity plan
B) Reimbursement plan
C) Fee-for-service plan
D) Prepaid plan

A

Prepaid plan.

49
Q

Which of the following is NOT true of basic medical expense plans?

A) Coverage for catastrophic medical expenses
B) No deductibles
C) First-dollar coverage
D) Low dollar limits

A

Coverage for catastrophic medical expenses.

50
Q

How is emergency care covered for a member of HMO?

A) A member of an HMO can receive care in or out of the HMO service area, but care is preferred in the service area
B) A member of an HMO may receive care at any emergency facility, at the same cost as if in his/her own service area
C) HMOs have salaried member physicians, but they do not cover emergency care
D) An HMO emergency specialist will cover the patient

A

A member of an HMO can receive care in or out of the HMO service area, but care is preferred in the service area.

51
Q

What is the goal of the HMO?

A) Providing free health services
B) Limiting the deductibles and coinsurance to reduce costs
C) Providing health services close to home
D) Early detection through regular checkups

A

Early detection through regular checkups.

52
Q

In individual health insurance coverage, the insurer must cover a newborn from the moment of birth, and if additional premium payment is required, all how many days for payment?

A) Within 10 calendar days
B) Within 15 calendar days
C) Within 31 days of birth
D) Within a reasonable period of time

A

Within 31 days of birth.

53
Q

Which of the following are responsible for making premium payments in an HMO plan?

A) Insureds
B) Payors
C) Subscribers
D) Producers

A

Subscribers.

54
Q

An insured has a major medical policy with a $500 deductible and a coinsurance clause of 80/20. If he incurs medical expenses of $4,000, the insurer would pay

A) $3,200
B) $3,500
C) $2,500
D) $2,800

A

$2,800.

55
Q

In major medical insurance policies, when the insured’s share of coinsurance reaches a certain amount, the insured is no longer obligated to pay it. This feature is known as

A) Stop-loss
B) Maximum benefits
C) Deductible
D) Coordination of benefits

A

Stop-poss.

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