Chap. 5 Flashcards
Individual insurance does not require medical examinations, while group insurance does require medical examinations.
A: Controlled access to providers, comprehensive case management, preventive care, risk sharing, and high quality care
Q: What are usual/reasonable and customary charges based on?
A: Average charge for a given procedure in the specific geographic area
Q: What is the main principle of an HMO plan?
A: Preventive care
Q: What are the three types of basic medical expense insurance?
A: Hospital, surgical and medical
Q: Under what type of care do insurers negotiate contracts with health care providers to allow subscribers access to health care services at a favorable cost?
A: Preferred Provider Organization (PPO)
When health care insurers negotiate contracts with health care providers or physicians to provide health care services for subscribers at a favorable cost, it is called
Preferred Provider Organization (PPO).
An employee becomes insured under a PPO plan provided by his employer. If the insured decides to go to a physician who is not a PPO provider, which of the following will happen?
The PPO will pay reduced benefits.
Q: In what type of health plans are providers paid for services in advance, regardless of the services provided?
A: Prepaid plans
Q: What is the purpose of the coinsurance provision in health insurance policies?
A: To prevent overutilization of the policy benefits
Q: What are the tax implications for contributions to a Health Savings Accounts by the individual insured?
A: Contributions are tax deductible
Q: What provision provides for the sharing of expenses between the insured and the insurance company?
A: Coinsurance
Q: What is the main difference between coinsurance and copay?
A: Copay is a set dollar amount; coinsurance is a percentage of the expenses
Q: What types of injuries and services will 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, and elective cosmetic surgery
Q: What type of health insurance plans cover all accidents and illnesses that are not specifically excluded in the policy?
A: Comprehensive plans
Q: What is the purpose of managed care health insurance plans?
A: To control health insurance claims expenses
Q: Can an insured who belongs to a POS plan use an out-of-network physician?
A: Yes, but the copays and deductibles may be higher
Q: How can an HMO member see a specialist?
A: Referral by the primary care physician
How does a member of an HMO see a specialist?
The primary care physician refers to the member.
Q: What are the two types of Flexible Spending Accounts?
A: Health care accounts and dependent care accounts
Q: What is the role of the gatekeeper in an HMO plan?
A: To control costs for the services of specialists
Which of the following is another name for a primary care physician in an HMO?
Gatekeeper
The gatekeeper of an HMO helps
Control specialist costs.
Q: Who chooses a primary care physician in an HMO plan?
A: The individual member
Q: How are HMO territories typically divided?
A: Geographic areas
Q: What is a fee-for-service health plan?
A: Under a fee-for-service plan, providers receive payments for each service provided
Q: When are newborns covered in individual health insurance policies?
A: From the moment of birth
In individual health insurance coverage, the insurer must cover a newborn from the moment of birth, and if additional premium payment is required, how many days should be allowed for payment?
Within 31 days of birth
Q: Why do HMOs encourage members to get regular checkups?
A: To help catch health problems early when treatment has the greatest chance for success (i.e. preventive care)
A health insurance plan which involves financing, managing, and delivery of health care services and involves a group of providers who share in the financial risk of the plan or who have an incentive to deliver cost effective service, is called
Managed care plan.
When is the annual open enrollment for state insurance exchanges?
November 1 through January 31
A man’s physician submits claim information to his insurer before she actually performs a medical procedure on him. She is doing this to see if the procedure is covered under the patient’s insurance plan and for how much. This is an example of
Prospective review.
What process will the insurance company use to monitor the insured’s hospital stay to make sure that everything is proceeding according to schedule?
Concurrent review
Which of the following answers does NOT describe the principal goal of a Preferred Provider Organization?
Provide medical services only from physicians in the network
When an insurer offers services like preadmission testing, second opinions regarding surgery, and preventative care, which term would best apply?
Case management provision
Under the Affordable Care Act, which classification applies to health plans based on the amount of covered costs?
Metal level classification
An insured’s health claim internal appeal was denied. The insurer must do all of the following EXCEPT
Offer a payment plan.
In health insurance, if a doctor charges $50 more than what the insurance company considers usual, customary and reasonable, the extra cost
Is not covered.
Q:Under which provision can a physician submit claim information prior to providing treatment?
Q:What would a physician utilize if he/she wanted to know if a treatment is covered under an insured’s plan and at what rate it will be paid?
Prospective Review
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
Any children born to them after the inception of the contract.
Which of the following is NOT a cost-saving service in a medical plan?
Denial of coverage
What term is used to describe when a medical caregiver contracts with a health organization to provide services to its members or subscribers, but retains the right to treat patients who are not members or subscribers?
Open panel
A man bought an individual health insurance policy for himself. Which of the following roles does he now legally have?
Both subscriber and insured
Which of the following is NOT a characteristic or a service of an HMO plan?
Contracting with insurance companies
A woman obtains health coverage through the Marketplace on October 1. Two weeks later she finds out that she is 3 months pregnant. Which of the following is true about coverage for pregnancy?
Pregnancy will be covered immediately.
Which of the following individuals will be eligible for coverage on the Health Insurance Marketplace?
A permanent resident lawfully present in the U.S.
Which of the following would NOT be used in preventive care?
Chemotherapy
Most health insurance policies exclude all of the following EXCEPT
Accidental injury.
All of the following may be excluded from coverage in a Major Medical Expense policy, EXCEPT
Emergency surgery.
A medical expense policy that establishes the amount of benefit paid based upon the prevailing charges which fall within the standard range of fees normally charged for a specific procedure by a doctor of similar training and experience in that geographic area is known as
Usual, customary and reasonable.
Which of the following hospice expenses would NOT be covered in a cost-containment setting?
Antibiotics
Which of the following health care plans would most likely provide the insured/subscriber with comprehensive health care coverage?
Health Maintenance Organization plan
On a major medical insurance policy, the amount that an insured must pay on a claim before the insurer will pay is known as
Deductible.
According to the provisions of the Patient Protection and Affordable Care Act, all of the following are required preventive care services EXCEPT
Cervical cancer exams for all women starting at age 40.
An applicant has a history of heart disease in his family, so he would like to buy a health insurance policy that strictly covers heart disease. What type of policy is this?
Dread disease coverage
An insured is admitted to the hospital for surgery on a herniated disk. The insurance company monitors the treatment and progress in order to make sure that everything proceeds according to the insurer’s schedule. This is called
Concurrent review.
If an employer health care plan is grandfathered, it is required to
Cover dependent children to age 26.
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?
Notify the insurer within 31 days in order for coverage to continue without any evidence of insurability
What is the maximum age for qualifying for a catastrophic plan?
30
