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Insurance Cert > Chapter 14 > Flashcards

Chapter 14 Flashcards

1
Q

What is an Administration Services Only (ASO) Plan?

A

This is a contract in which a self-funded employee welfare benefit plan contracts with an insurer for administrative services while remaining responsible for the cost of claims. The insurer acts as a third-party administrator (TPA).

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2
Q

What is Adverse Selection?

A

This describes the reality that persons who are most likely to suffer a loss are also the most likely to seek insurance. It also describes the negative financial impact when the percentage of high-risk participants is too high.

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3
Q

What does Blue Cross cover?

A

This is the part of Blue Cross and Blue Shield that covers hospital services.

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4
Q

What is Blue Cross and Blue Shield?

A

This is an insurance service provider that pays participating medical providers directly for a subscriber’s treatment rather than reimbursing the insured.

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5
Q

What does Blue Shield cover?

A

This is the part of Blue Cross and Blue Shield that covers the treatment costs of physicians and other medical providers.

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6
Q

What is Capitation?

A

This is a method for compensating healthcare providers and is calculated per patient rather than per service. HMOs pay providers a flat amount per person.

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7
Q

What is Case Management (Utilization Review)?

A

This is the process by which a specialist within a person’s insurer reviews potentially large claims to discuss treatment alternatives with the insured.

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8
Q

What is a Change of Life Event?

A

This is a commonly experienced occurrence that tends to cause individuals to buy insurance that’s unrelated to a specific increase in risk. Examples include marriage, divorce, or the birth of a child.

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9
Q

What is a Certificate of Insurance?

A

This is the document that’s received by group plan participants, which demonstrates their coverage under a group plan.

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10
Q

What is a Closed-Panel Network?

A

This is a form of health maintenance organization (HMO) in which providers deliver services within HMO facilities.

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11
Q

What does COBRA stand for?

A

See Consolidated Omnibus Budget Reconciliation Act.

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12
Q

What is a COBRA Group?

A

A group that has 20 or more employees and must comply with COBRA mandates.

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13
Q

What is a COBRA Qualifying Event?

A

See Qualifying Event (COBRA).

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14
Q

What is Co-Insurance?

A

This is a cost-sharing formula in which subscribers pay a percentage of their medical costs up to an annual maximum.

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15
Q

What is Community Rating?

A

This is a measurement that’s used to project a client’s level of risk. Insurers use it when underwriting and setting the premium for small group insurance plans.

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16
Q

What is Concurrent Review?

A

This is a form of utilization review in which health care is reviewed as it’s being provided.

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17
Q

What is the Consolidated Omnibus Budget Reconciliation Act (COBRA)?

A

COBRA mandates that employers provide employees and their qualified beneficiaries with continuing coverage through the company’s group health plan following a qualifying event.

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18
Q

What is a Contributory Plan?

A

This is a group insurance plan in which the employees and the employer share the cost of coverage.

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19
Q

What is Conversion Privilege?

A

This privilege allows individuals who are covered under group plans to convert their coverage to individual policies when their access to insurance through their group plan ends.

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20
Q

What is a Co-Payment or Co-Pay?

A

This is a fixed dollar amount that HMO subscribers pay per visit.

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21
Q

What is Creditable Coverage?

A

This is defined by HIPAA as previous coverage under another insurance plan when there has not been a break in coverage that lasts 63 days or longer.

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22
Q

What is a Dental Maintenance Organization (DMO)?

A

This is a health maintenance organization for dental services.

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23
Q

What is an Employee Welfare Benefit Plan?

A

This is an ERISA compliant plan that’s funded by employers and provides employees benefits other than pensions.

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24
Q

What is an Enrollment Card?

A

This must be completed and signed by a new employee during the open enrollment period to enroll in group insurance.

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25
Q

What is an Enrollment Period?

A

This is the limited period during which all members may sign up for a group plan.

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26
Q

What is Evidence of Insurability?

A

This is considered proof that a prospective group plan participant is an acceptable medical risk.

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27
Q

What is Evidence of Insurance?

A

See Certificate of Insurance.

28
Q

What is an Exclusive Provider Organization (EPO)?

A

This is a hybrid of an HMO and a PPO.

29
Q

What is Experience Rating?

A

This is a measurement that’s used to project a client’s level of risk when underwriting large group insurance.

30
Q

What is an Extension of Benefits?

A

This provision allows a covered individual to continue receiving benefits for a covered claim, even after the individual is no longer eligible for coverage.

31
Q

What are Franchise Health Plans (Wholesale Plans)?

A

These plans provide health insurance coverage to members of an association or professional society.

32
Q

What is a Gatekeeper?

A

See Primary Care Physician.

33
Q

What is Group Health Insurance?

A

This is insurance for a group of people, often employees of a company, under one master contract.

34
Q

What is a Group Model HMO (Closed Panel)?

A

Under this model, the HMO pays a capitation or a predetermined price for the provider group.

35
Q

What is the Health Insurance Portability and Accountability Act (HIPAA)?

A

This is a federal law that was passed in 1997 which guarantees American workers have the ability to transfer and continue health insurance coverage when they change or lose their jobs.

36
Q

What are Health Maintenance Organizations (HMOs)?

A

This is an organization that offers comprehensive prepaid health care services to its subscribing members.

37
Q

What is Increased Persistency?

A

Unlike individual policies, group plans continue in existence despite the fact that individual participants may leave or join.

38
Q

What are Indemnity Plans (Major Medical Insurance)?

A

These are traditional insurance plans that are not involved with organizing or administering provider networks.

39
Q

What are Independent Practice Association (IPA) HMOs?

A

These HMOs are characterized by a network of physicians who work out of their own facilities and participate in the HMO on a part-time basis.

40
Q

What is an Individual Practice Association?

A

This is synonymous with an Independent Practice Association.

41
Q

What is a Master Contract?

A

This is the group insurance policy that’s issued to the group sponsor by the insurance company.

42
Q

Who is the Master Policy owner?

A

This is the group sponsor that has entered into a contract for group insurance with an insurance company.

43
Q

What is a Multiple Employer Trust (MET)?

A

An MET combines multiple employers (10 or more) into a single pool to provide group insurance.

44
Q

What is a Multiple Employer Welfare Arrangement (MEWA)?

A

MEWAs consist of two or more employers with a common bond who join together to provide health benefits for their employees on a self-insured basis.

45
Q

What is a Natural Group?

A

This is an organization that exists for some reason other than to obtain insurance.

46
Q

What is a Network Model HMO (Closed Panel)?

A

This network model is similar to the group model; however, it involves more than one physician group.

47
Q

What is a Non-Contributory Plan?

A

This is a group insurance plan in which the employer pays the entire group premium.

48
Q

What is a Notice of Privacy Practices?

A

HIPAA requires health insurance plans to provide new subscribers with a Notice of Privacy Practices at the time of enrollment.

49
Q

What is an Open-Panel Network?

A

This network is a form of HMO in which providers deliver services while working out of their own offices on a part-time basis.

50
Q

What are Participating Providers?

A

These are doctors and hospitals that contractually agree to specific fees for the services they provide to Blue Cross and Blue Shield subscribers.

51
Q

What is Persistency?

A

This describes the degree to which existing policies remain in force.

52
Q

What is a Point of Services (POS) Plan?

A

This plan combines in-network care that’s similar to an HMO with limited out-of-network care resembling an indemnity plan.

53
Q

What is Pre-Admission Certification?

A

This typically involves evaluating an individual’s overall health before being hospitalized for surgery to determine whether the requested treatment is medically necessary.

54
Q

What is a Preferred Provider Organization (PPO)?

A

This is a sponsored network of health care providers that contract with the PPO to offer their services to PPO subscribers.

55
Q

What is the Pregnancy Discrimination Act of 1978?

A

As an amendment to the Civil Rights Act of 1964, this act requires that women who are affected by a pregnancy, childbirth, or related medical conditions be treated the same as any other person for employment-related purposes.

56
Q

What is a Primary Care Physician (PCP)?

A

This is a doctor who provides general medical care for individual network members and controls all of their referrals for specialized care.

57
Q

What is Prospective Review?

A

This is a form of utilization review that involves analyzing a case before admission to determine the type of treatment that’s necessary.

58
Q

What is a Qualifying Event (COBRA)?

A

This type of event qualifies workers and beneficiaries to access COBRA benefits.

59
Q

What is a Retrospective Review?

A

This is a form of utilization review that occurs after medical treatment is provided.

60
Q

What is a Service Basis?

A

This is a system of insurance coverage in which consumers contract with service providers to obtain medical services from participating providers in exchange for a premium.

61
Q

What are Service Providers?

A

In exchange for a premium, service providers offer benefits to subscribers in the form of services by participating providers.

62
Q

What is a Small Employer?

A

A small employer is generally defined as a business that has 50 or fewer employees.

63
Q

What is a Staff Model (Closed Panel) HMO?

A

This HMO provides care through physicians and hospitals that are HMO employees.

64
Q

What are Taft-Hartley Trusts?

A

These are trusts that are negotiated trusteeships resulting from collective bargaining between a labor union and employer.

65
Q

What are Third-Party Administrators (TPAs)?

A

This is an independent organization that provides administrative services for group insurance sponsors.

66
Q

What is Utilization Review?

A

See Case Management.

Insurance Cert (20 decks)

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