Ch 5 Medical Plans

Question 1

A request for a higher authority to review the decision

Answer 1

Appeal

Question 2

Covers members of a particular group when they are participating in a particular activity, without naming individual insureds (such as students, passengers, sports teams)

Answer 2

Blanket policy

Question 3

A payment arrangement that pays a physician or group of physicians a set amount for each enrolled person assigned to them, Per period of time, whether or not that person seeks care.

Answer 3

Capitation

Question 4

A primary care physician (PCP) in an HMO plan

Answer 4

Gatekeeper

Question 5

Pays health policy benefits to the insured based on a predetermined, fixed rate, regardless of the actual expense incurred

Answer 5

Indemnity plan

Question 6

Policy termination at its expiration date

Answer 6

Nonrenewable

Question 7

Amounts and insured must pay for coinsurance and deductible before the insurance will pay its portion

Answer 7

Out of pocket expenses

Question 8

The active repaying a party who has spent or lost money

Answer 8

Reimbursement

Question 9

The amount the insured pays out of pocket during the year

Answer 9

Stop loss

Question 10

A person who signs up for a prepaid health plan, such as an HMO

Answer 10

Subscriber

Question 11

Higher deductible =

Answer 11

Lower premium

Question 12

The main foucs for an HMO is:

Answer 12

Preventive care

Question 13

In an HMO, a ______________ helps control the cost of healthcare by only making the necessary referrals.

Answer 13

gatekeeper

Question 14

Unlike HMOs, PPOs allow more flexibility between an in-network and out-network providers, in exchange for a higher premium.

Answer 14

True

Question 15

Non-health withdrawals before age 65 = _________ non-health withdrawals after age 65 = __________.

Answer 15

20% penalty; no penalty.

Question 16

HRAs allow employees to rollover unused benefits to the following calendar year, in addition to new benefits.

Answer 16

True

Question 17

The affordable care act requires all individual and group health insurance plans be issued on a guaranteed issue basis.

Answer 17

True

Question 18

Individual catastrophic plans that cover essential benefits are available for adults under age 30 and individuals who cannot obtain affordable coverage.

Answer 18

True

Question 19

Under the affordable care act, premium discounts may be awarded to low income individuals, regardless of the chosen metal levels

Answer 19

True

Question 20

Payments are made continuously, regardless of services provided

Answer 20

Prepaid plans

Question 21

Limit services to one illness or group of coverage

Answer 21

Specified coverages

Question 22

Provide coverage for most types of medical expenses

Answer 22

Comprehensive care

Question 23

State exact coverages under a plan and given costs

Answer 23

Benefit schedule

Question 24

Major medical insurance (Indemnity Plans)

Answer 24

• High maximum limits
• blanket coverage
• deductibles paid upfront
• cost shared after meeting deductible

Question 25

Healthcare services organization (HMOs)

Answer 25

- Preventative care - prepaid basis - Limited to service area - Basic benefit services - optional benefits

Question 26

Hospital inpatient, physician, outpatient medical, preventative, urgent care, emergency, diagnostic laboratory, out of area coverage

Answer 26

Basic benefit services

Question 27

Long-term care, nursing services, home health care, prescription drugs, dental/vision care, mental healthcare, substance abuse services

Answer 27

Optional benefits

Question 28

Preferred provider organizations (PPOs)

Answer 28

- physicians are paid on a fee-for-service basis - no PCP referrals - members can use any position they choose but they are encouraged to use approved physicians who have previously agreed-upon fees

Question 29

Point of service plans (POS)

Answer 29

- combination of HMO and PPO plans - employees not locked into one plan; allowed to choose depending on the need for medical services - nonmember physicians are paid service fee; patient pays higher coinsurance

Question 30

Cost saving services

Answer 30

Preventative care, hospitalization alternatives, second opinion, preadmission testing, catastrophic case management, risk sharing, high quality of care

Question 31

Claim information submitted before treatment

Answer 31

Perspective review

Question 32

Claim information submitted after treatment

Answer 32

Retrospective review

Question 33

Insured's hospital stay monitored and plan for release

Answer 33

Concurrent review

Question 34

Managed care

Answer 34

- Financial incentives for using approved providers or procedures - primary focus of preventative care Improved case management through utilization review - Control length of hospital stay

Question 35

Affordable care act

Answer 35

- Mandates preventative, educational, and community-based healthcare - children are covered until age 26 - coverage of pre-existing conditions

Question 36

Metal levels/plan covers:

Answer 36

Bronze 60% silver 70% gold 80% platinum 90%

Question 37

Hospitalization, maternity, emergency services, wellness and preventative services, chronic disease management

Answer 37

Essential benefits Affordable care act

Question 38

Basic hospital, surgical and medical policies, as well as major medical policies are considered what type of insurance?

Answer 38

Medical expense insurance

Question 39

What are some of the characteristics of a major medical expense policy?

Answer 39

High maximum limits, blanket coverage, coinsurance, and deductibles

Question 40

Preventive care services are a hallmark of what type of health care provider?

Answer 40

Health maintenance organization (HMO)