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health ins > Chap. 5 > Flashcards

Chap. 5 Flashcards

1
Q

Individual insurance does not require medical examinations, while group insurance does require medical examinations.

A

A: Controlled access to providers, comprehensive case management, preventive care, risk sharing, and high quality care

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2
Q

Q: What are usual/reasonable and customary charges based on?

A

A: Average charge for a given procedure in the specific geographic area

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3
Q

Q: What is the main principle of an HMO plan?

A

A: Preventive care

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4
Q

Q: What are the three types of basic medical expense insurance?

A

A: Hospital, surgical and medical

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5
Q

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

A: Preferred Provider Organization (PPO)

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6
Q

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

A

Preferred Provider Organization (PPO).

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7
Q

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?

A

The PPO will pay reduced benefits.

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8
Q

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

A

A: Prepaid plans

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9
Q

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

A

A: To prevent overutilization of the policy benefits

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10
Q

Q: What are the tax implications for contributions to a Health Savings Accounts by the individual insured?

A

A: Contributions are tax deductible

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11
Q

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

A

A: Coinsurance

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12
Q

Q: What is the main difference between coinsurance and copay?

A

A: Copay is a set dollar amount; coinsurance is a percentage of the expenses

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13
Q

Q: What types of injuries and services will be excluded from major medical coverage?

A

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

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14
Q

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

A

A: Comprehensive plans

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15
Q

Q: What is the purpose of managed care health insurance plans?

A

A: To control health insurance claims expenses

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16
Q

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

A

A: Yes, but the copays and deductibles may be higher

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17
Q

Q: How can an HMO member see a specialist?

A

A: Referral by the primary care physician

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18
Q

How does a member of an HMO see a specialist?

A

The primary care physician refers to the member.

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19
Q

Q: What are the two types of Flexible Spending Accounts?

A

A: Health care accounts and dependent care accounts

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20
Q

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

A

A: To control costs for the services of specialists

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21
Q

Which of the following is another name for a primary care physician in an HMO?

A

Gatekeeper

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22
Q

The gatekeeper of an HMO helps

A

Control specialist costs.

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23
Q

Q: Who chooses a primary care physician in an HMO plan?

A

A: The individual member

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24
Q

Q: How are HMO territories typically divided?

A

A: Geographic areas

25
Q

Q: What is a fee-for-service health plan?

A

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

26
Q

Q: When are newborns covered in individual health insurance policies?

A

A: From the moment of birth

27
Q

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?

A

Within 31 days of birth

28
Q

Q: Why do HMOs encourage members to get regular checkups?

A

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

29
Q

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

A

Managed care plan.

30
Q

When is the annual open enrollment for state insurance exchanges?

A

November 1 through January 31

31
Q

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

A

Prospective review.

32
Q

What process will the insurance company use to monitor the insured’s hospital stay to make sure that everything is proceeding according to schedule?

A

Concurrent review

33
Q

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

A

Provide medical services only from physicians in the network

34
Q

When an insurer offers services like preadmission testing, second opinions regarding surgery, and preventative care, which term would best apply?

A

Case management provision

35
Q

Under the Affordable Care Act, which classification applies to health plans based on the amount of covered costs?

A

Metal level classification

36
Q

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

A

Offer a payment plan.

37
Q

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

A

Is not covered.

38
Q

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?

A

Prospective Review

39
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.

40
Q

Which of the following is NOT a cost-saving service in a medical plan?

A

Denial of coverage

41
Q

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?

A

Open panel

42
Q

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

A

Both subscriber and insured

43
Q

Which of the following is NOT a characteristic or a service of an HMO plan?

A

Contracting with insurance companies

44
Q

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?

A

Pregnancy will be covered immediately.

45
Q

Which of the following individuals will be eligible for coverage on the Health Insurance Marketplace?

A

A permanent resident lawfully present in the U.S.

46
Q

Which of the following would NOT be used in preventive care?

A

Chemotherapy

47
Q

Most health insurance policies exclude all of the following EXCEPT

A

Accidental injury.

48
Q

All of the following may be excluded from coverage in a Major Medical Expense policy, EXCEPT

A

Emergency surgery.

49
Q

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

A

Usual, customary and reasonable.

50
Q

Which of the following hospice expenses would NOT be covered in a cost-containment setting?

A

Antibiotics

51
Q

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

A

Health Maintenance Organization plan

52
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

Deductible.

53
Q

According to the provisions of the Patient Protection and Affordable Care Act, all of the following are required preventive care services EXCEPT

A

Cervical cancer exams for all women starting at age 40.

54
Q

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?

A

Dread disease coverage

55
Q

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

A

Concurrent review.

56
Q

If an employer health care plan is grandfathered, it is required to

A

Cover dependent children to age 26.

57
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 within 31 days in order for coverage to continue without any evidence of insurability

58
Q

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

A

30

health ins (10 decks)

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