Ch. 2-Health insurance

Question 1

Adverse selection

Answer 1

Enrollment of an excessive proportion of persons with poor health status in a healthcare plan or healthcare organization

Question 2

Appeal

Answer 2

Request for reconsideration of denial of coverage or rejection of claim

Question 3

Benefit

Answer 3

Healthcare service for which the healthcare insurance company will pay

Question 4

Benefit period

Answer 4

Length of time that a health insurance policy will pay benefits for the member, family, and dependents

Question 5

Certificate of insurance

Answer 5

Formal contract between a healthcare insurance company and individuals or groups purchasing the healthcare insurance that details the provisions of the healthcare insurance policy
AKA certificate of coverage, evidence of coverage, or summary plan description

Question 6

Claim

Answer 6

Request for payment, or itemized statement of healthcare services and their costs, provided by a hospital, physician’s office, or other healthcare provider.
Submitted to insurance plan by policyholder or provider

Question 7

Coinsurance

Answer 7

Cost sharing provision which is a pre established percentage of eligible expenses to be paid by the beneficiary after the deductible has been met

Question 8

Community rating

Answer 8

Method of determining healthcare premium rates by geographic area (community) rather than by age, health status, or company size.
Increases the size of the risk pool; costs are increased to younger, healthier individuals who are subsidizing older individuals

Question 9

Coordination of benefits (COB)

Answer 9

Method of integrating benefit payments from multiple healthcare insurers to ensure that payments do not exceed 100% of the covered healthcare expenses

Question 10

Co-payment

Answer 10

Cost sharing measure in which the beneficiary pays a fixed dollar amount per service, supply, or procedure that is owed to the healthcare facility by the patient

Question 11

Cost sharing

Answer 11

Provision of a healthcare insurance policy that requires policyholders to pay for a portion of their healthcare services; cost-control mechanism

Question 12

Covered condition

Answer 12

Health condition, illness, injury, disease, or symptom for which the healthcare insurance company will pay for treatment

Question 13

Covered service

Answer 13

Specific service for which a healthcare insurance company will pay

Question 14

Deductible

Answer 14

Annual amount of money that the policyholder must incur and pay before the health insurance plan will assume liability for the remaining charges or covered expenses

Question 15

Dependent

Answer 15

An insured’s spouse, children and young adults(until they’re 26) and dependents with disabilities without an age limit
Children are defined as natural children, adopted children, stepchildren, and children who are dependent during adoption waiting period

Question 16

Disease management

Answer 16

Program focused on preventing exacerbations of chronic diseases and on promoting healthier lifestyles for patients and clients with chronic diseases

Question 17

Eligibility

Answer 17

Set of stipulations that qualify a person to apply for healthcare insurance

Question 18

Employer-based health insurance

Answer 18

Coverage obtained by an individual or family as part of an employment benefit package

Question 19

Enrollment

Answer 19

Initial process in which new individuals apply and are accepted as beneficiaries of healthcare insurance plans

Question 20

Evidence-based clinical practice guidelines

Answer 20

Explicit statement that guides clinical decision making and has been systemically developed from scientific evidence and clinical expertise too answer clinical questions

Question 21

Exclusion

Answer 21

Situation, instance, condition, injury, or treatment that the healthcare plan states will not be covered and for which the healthcare plan will pay no benefits

Question 22

Family coverage

Answer 22

Healthcare insurance coverage for dependents of the policyholder, such as spouse and children

Question 23

Formulary

Answer 23

A list of prescription drugs that a health insurance plan will cover or allow to be reimbursed

Question 24

Gatekeeper

Answer 24

Healthcare provider or entity responsible for determining the healthcare services a patient or client may access
May be primary care provider, utilization review or case management agency, or a managed care organization

Question 25

Guaranteed issue

Answer 25

Federal requirement that a healthcare insurer allow individuals to enroll in the health plan regardless of their health, sex, age, or other factors that might predict use of health services

Question 26

Health maintenance organization (HMO)

Answer 26

Entity that combines the provision of healthcare insurance and the delivery of healthcare services Characterized by; organized healthcare delivery system to a geographic area, set of basic and supplemental health maintenance and treatment services, voluntarily enrolled members, and predetermined fixed periodic prepayments for members coverage

Question 27

Individual health insurance

Answer 27

Coverage that is purchased by an individual or family on their own (not through employer)

Question 28

Limitation

Answer 28

Qualification or other specification that reduces or restricts the extent of the healthcare benefit.

Question 29

Managed care

Answer 29

Payment method in which the third party payer has implemented some provisions to control the costs of healthcare while maintaining quality care Systemic merger of clinical, financial, and administrative processes to manage access, cost, and quality of healthcare

Question 30

Maximum out of pocket

Answer 30

Specific amount, in a certain timeframe, beyond which all covered healthcare services for that policyholder of dependent are paid at 100% by the healthcare insurance plan

Question 31

Medically necessary

Answer 31

Healthcare services and supplies that are proper and needed for the diagnosis or treatment of medical conditions; are provided for the diagnosis, direct care, and treatment of medical conditions; meet the standards of good medical practice in the local area; are not mainly for the convenience of the beneficiary or the doctor

Question 32

Moral hazard

Answer 32

The lack of incentive to guard against risk risk where one is protected from its consequences. Includes any change in behavior that occurs as a result of becoming insured

Question 33

Open enrollment period

Answer 33

Period during which individuals may elect to enroll in, modify coverage, or transfer between healthcare insurance plans, usually without evidence of insurability or waiting periods

Question 34

Other party liability (OPL)

Answer 34

Method of determining responsibility for health expenses when non health insurance sources are involved

Question 35

Pharmacy benefit manager (PBM)

Answer 35

A specialty benefit management organization that provides comprehensive pharmacy services They administer healthcare insurance companies prescription drug benefits for insurance companies or self-insured employers

Question 36

Point-of-service (POS) plan

Answer 36

Managed care plan where members choose how to receive services at the time they need them Members can choose at the point of service whether they want an HMO, a PPO, or a fee schedule plan

Question 37

Policy

Answer 37

Binding contact issued by a healthcare insurance company to an individual or group in which the company promises to pay for healthcare to test illness or injury

Question 38

Preferred provider organization (PPO)

Answer 38

Entity that contracts with employees and insurers, through a network of providers, to render healthcare services to a group of members Members can choose to use the healthcare services of any physician, hospital, or other healthcare provider. Network providers have lower out of pocket expenses than out of pocket expenses

Question 39

Primary care provider (PCP)

Answer 39

Healthcare provider who provides, supervises, and coordinates the healthcare of a member Includes general practitioners, internists, pediatricians, ob/gyns, nurse practitioners, physician's assistants, etc.

Question 40

Primary insurer

Answer 40

Entity responsible for the greatest proportion or majority of the healthcare expenses

Question 41

Prior authorization

Answer 41

Process of obtaining approval from a healthcare insurance company before receiving healthcare services AKA pre-certification, or pre-authorization

Question 42

Prudent layperson standard

Answer 42

Standard for determining the need for emergency care based on what an ordinary person would believe or decide.

Question 43

Qualifying life event (QLE)

Answer 43

Changes in an individuals life that make him or her eligible for a special enrollment period. Ex: moving, marriage, divorce, income changes, etc.

Question 44

Referral

Answer 44

A process in which a PCP makes a request to a managed care plan on behalf of the patient to send them to receive medical care from a specialist or provider outside the managed care plan

Question 45

Risk

Answer 45

the likelihood of an individual to incur a healthcare expense or probability of incurring a loss

Question 46

Secondary insurer

Answer 46

Entity responsible for the remainder of healthcare expenses after the primary insurer

Question 47

Single coverage

Answer 47

healthcare coverage only for the policyholder/employee

Question 48

Special enrollment period

Answer 48

an enrollment period limited to certain circumstances that occurs without regard to the health insurance company's regularly scheduled open enrollment; driven by qualifying life events(marriage, death, divorce, birth, etc)

Question 49

Summary of Benefits and Coverage (SBC)

Answer 49

A document that, in plain language, concisely details information about a health insurance company's benefits and it's coverage of health services

Question 50

Supplemental insurance

Answer 50

policies that fill in the coverage of other policies; fills gaps of services not provided by main insurance EX: accidental death, long term disability, short term health insurance for trip/vacation

Question 51

Tier

Answer 51

level of coverage; act as limits

Question 52

Utilization Management

Answer 52

a program that evaluates the healthcare facility's overall efficiency in providing necessary care to patients in the most effective manner; primary cost control tool

Question 53

Utilization review

Answer 53

a process that determines the medical necessity of a procedure and the appropriateness of the setting for the healthcare service in the continuum of care

Question 54

Waiting period

Answer 54

period that must pass before coverage for an employee or dependent who is otherwise eligible to enroll under the terms of a group health plan can become effective -does not apply to individual health plan; cannot exceed 90 days

Question 55

Withhold amount

Answer 55

part of the provider's prospective payment that the managed care plan deducts and holds to pay for excessive expenditures for expensive healthcare services such as referral to specialist

Question 56

Major types of health insurance

Answer 56

Individual, employer-based, or government sponsored Single or family coverage

Question 57

Provisions of a health insurance policy

Answer 57

certificate of insurance describing conditions of the insurance policy(what is and isn't covered) and the summary of benefits and coverage that simply details the company's benefits and coverage

Question 58

Characteristics of managed care

Answer 58

Quality- selection of providers, health of populations, care management tools, quality assessment and improvement Cost-effectiveness- Service management tools(utilization management and review), prospective reimbursement, financial incentives

Question 59

Common care management tools used in managed care

Answer 59

coordination of care, disease management, and application of evidence-based practice guidelines

Question 60

Cost controls used in managed care

Answer 60

utilization management and review; gatekeeper rule of PCP; prior authorization; second and third opinions; case management; prescription management; payment rate established in advance of an episode of care; providers to meet fiscal targets; members to use providers associated with the plan

Question 61

Types of managed care organizations

Answer 61

HMO (Health Maintenance Organization) -limited providers PPO (Preferred Provider Organization) -more options for provider, benefits for using preferred POS Plan (Point Of Service) -decide at time of service if it will be HMO, PPO, or fee schedule plan.