Ch 5 Medical Plans Part II

Question 1

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

Answer 1

Comprehensive plans

Question 2

What type of injuries and services will be excluded from major medical coverage?

Answer 2

Injuries caused by war, intentionally self-inflicted injuries, injuries covered by Worker’s Compensation, regular dental/vision/hearing care, custodial care, and elective cosmetic surgery

Question 3

What are the two types of flexible spending account?

Answer 3

Health care accounts and dependent care account

Question 4

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

Answer 4

Contributions are tax deductible

Question 5

What are the three types of basic medical expense insurance?

Answer 5

Hospital, surgical and medical

Question 6

What are the five basic characteristics of managed care plans?

Answer 6

1. controlled access to providers
2. comprehensive case management
   3 preventative care
   4 risk sharing
   5 high quality care

Question 7

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

Answer 7

To prevent over utilization of the policy benefits

Question 8

What is the main difference between coinsurance and co-pay?

Answer 8

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

Question 9

What is the main principle of an HMO plan?

Answer 9

Preventative care

Question 10

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

Answer 10

Prepaid plans

Question 11

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

Answer 11

Coinsurance

Question 12

When are newborns covered in individual health insurance policies?

Answer 12

From the moment of birth

Question 13

How are HMO territories typically divided?

Answer 13

Geographic areas

Question 14

What are usual/reasonable and customary charges based on?

Answer 14

Average charge for a given procedure in the specific geographic area

Question 15

Who chooses a primary care physician in an HMO plan?

Answer 15

The individual member

Question 16

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

Answer 16

Preferred provider organization (PPO)

Question 17

What is the purpose of managed care health insurance plans?

Answer 17

To control health insurance claims expenses

Question 18

Why do HMOs encourage members to get regular check ups?

Answer 18

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

Question 19

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

Answer 19

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

Question 20

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

Answer 20

To control cost for the services of specialists

Question 21

How can an HMO member see a specialist?

Answer 21

Referral by the primary care physician

Question 22

What is a fee-for-service health plan?

Answer 22

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