Chapter 5

Question 1

Comprehensive Care

Answer 1

Plans that provide coverage for most types of medical expenses; preventive care, routine physicals, immunizations, outpatient services, and hospitalization such as HMO’s

Question 2

Basic Medical Expense Policies

Answer 2

Low dollar limits and first dollar coverage, but no protection to an individual/family against catastrophic medical expenses that would be financially disastrous

Question 3

Major Medical Policy

Answer 3

Provides protection against catastrophic loss; uses deductibles and coinsurance to be made affordable

Question 4

Major Medical Characteristics

Answer 4

High maximum limits; blanket coverage; coinsurance; deductible that is paid up front

Question 5

Major Medical Exclusions

Answer 5

War injuries; intentional self-inflicted injuries; regular vision/dental/hearing care; custodial care; cosmetic surgery

Question 6

Major Medical Policy Premiums

Answer 6

Vary depending on deductible amount; coinsurance percentage; stop-loss amount; maximum amount of benefit

Question 7

Deductible for Major Medical

Answer 7

Higher deductible = lower premium

Question 8

Stop-Loss

Answer 8

The amount the insured pays out of pocket until reaching the stop-loss which when when the company will provide coverage at 100% of eligible expenses such as insured’s coinsurance and possibly the deductible; high stop-loss = low premium

Question 9

Major Medical Maximum Benefits

Answer 9

1 million or 2 million; usually lifetime maximums

Question 10

Health Maintenance Organizations (HMO)

Answer 10

Benefits are in the form of services versus reimbursement for the services of the physician or hospital

Question 11

HMO Service Area Limits

Answer 11

Limited to those living within certain geographic boundaries

Question 12

HMO Provider Limits

Answer 12

Care only provided from physicians who agree to a prenegotiated price

Question 13

HMO Prepaid Basis

Answer 13

The HMO receives a flat amount each month attributed to each member whether they see a physician or not

Question 14

HMO Main Goal

Answer 14

Reduced cost of health care by utilizing preventive care

Question 15

HMO Hospital Services

Answer 15

Members provided with inpatient hospital care in/out of service area

Question 16

HMO Basic Services

Answer 16

Hospital inpatient services; Physicians’ services; Outpatient medical services; Preventive Services; Urgent care services; Emergency care services; Diagnostic laboratory services; Out-of-area coverage

Question 17

HMO Optional Supplemental Benefits

Answer 17

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

Question 18

Preferred Provider Organizations (PPO)

Answer 18

A group of physicians and hospitals that provide medical care services at a reduced fee to employers, insurers, and third party organizations

Question 19

PPO General Characteristics

Answer 19

Paid a fee for service instead of salary; higher out of pocket costs and less coverage is provided when a member uses a physician not on the PPO list

Question 20

Point-of-Service (POS) Plans

Answer 20

A combination of HMO and PPO plans where a different choice can be made every time a need arises for medical services; provider network controlled by gatekeeping; members can self-refer at increased out of pocket costs but benefits covered are more expensive

Question 21

Managed Care Plans

Answer 21

Designed to control costs by controlling behavior of plan participants; Preventive care (annual physicals, mammograms, etc.) control length of hospital stay, utilization reviews to improve case management

Question 22

Utilization Management

Answer 22

A system used to review the appropriateness and efficient allocation of health care services and resources being given or proposed to be given to insured

Question 23

Prospective Review (Precertification)

Answer 23

Physician submits claim information prior to treatment to know what procedures will be covered at what rate

Question 24

Concurrent Review

Answer 24

Insured’s hospital stay is monitored to be sure that everything is going as planned

Question 25

Maternity Benefits

Answer 25

48 hours of inpatient care for normal vaginal delivery; 96 hours for caesarean delivery

Question 26

PA Mandated Benefits

Answer 26

Group policies must provide alcohol abuse/dependency benefits and serious mental illness; Maternity benefits for hospital stay/adopted children and newborns

Question 27

HIPAA (Health Insurance Portability and Accountability Act)

Answer 27

Regulates protection for both group health plans and for individual insurance policies

Question 28

Group Health Plans (HIPAA)

Answer 28

Prohibits discrimination against employees and dependents; allows opportunities to enroll in a new plan to individuals in special circumstances

Question 29

Individual Policies (HIPAA)

Answer 29

Guaranteed access to individual policies for qualified individuals; guaranteed renewability

Question 30

HIPAA Eligibility

Answer 30

Cannot establish eligibility rules for enrollment under the plan that discriminate based on any health factor: health status, medical conditions, claims experience, receipt of health care, medical history, genetic information, disability, evidence of insurability

Question 31

Eligibility to convert from group to individual under HIPAA

Answer 31

18 months of continuous coverage, been covered under a group plan in most recent coverage, not eligible for Medicare/Medicaid, not have any other insurance, apply within 63 days of losing prior insurance

Question 32

Affordable Care Act (ACA)

Answer 32

Set up a new competitive private health insurance market; keeping premiums low, preventing denials of care and allowing applicants with preexisting conditions to obtain coverage; stabilize budget and economy through reducing the deficit

Question 33

Affordable Care Act Eligibility

Answer 33

U.S. citizen, national, or lawfully present in the U.S.; live in U.S.; not currently incarcerated, not covered under Medicare

Question 34

Affordable Care Act premium rates

Answer 34

Depend on geographic rating area; family composition; age; tobacco use

Question 35

Affordable Care Act Essential Benefits

Answer 35

Hospitalization, maternity, emergency services, wellness, preventive services, chronic disease management

Question 36

Metal levels

Answer 36

Bronze - 60%, Silver 70%, Gold 80%, Platinum 90%

Question 37

Affordable Care Act enrollment

Answer 37

November 1st to January 31st

Question 38

Individual Mandate

Answer 38

All U.S. citizens and legal residents are required to have qualifying health care coverage