Health Policies and Plans

Question 1

“Basic” plans predated…

Answer 1

Modern health insurance

Question 2

Basic plans provided…

Answer 2

First dollar coverage, often with no cost-sharing from the patient

Question 3

Basic plans had…

Answer 3

Very low benefit limits by modern standards

Question 4

Hospital Expense Insurance

Answer 4

Covered hospital room and board and other hospital expenses

Question 5

HEI: Hospital Room and Board

Answer 5

Semi-private room and meals; had a certain per-day limit for specified number of days

Question 6

HEI: Other Hospital Expenses

Answer 6

Tests, supplies, medicine, transfusions; often capped at multiple of the per-day limit for room and board

Question 7

HEI: Had no coverage of…

Answer 7

Physician bills or outpatient services, even if care is at the hospital

Question 8

Surgical Expense Insurance

Answer 8

Covers inpatient or outpatient surgery based on type of procedure

Question 9

Fee Schedule

Answer 9

Covered amount for specific surgery will be based on preset max already set by insurer for that procedure, regardless of geography

Question 10

Reasonable and Customary Charges

Answer 10

Covered amount for specific surgery will depend on what most providers typically charge in the area

Question 11

Patients can be responsible for…

Answer 11

Amounts charged beyond fee schedule/reasonable and customary charges

Question 12

Surgery Second Opinions

Answer 12

Some non-emergency surgeries aren’t covered without a second opinion

Question 13

Surgery Second Opinion: Who will pay for second opinion?

Answer 13

Insurer

Question 14

Surgery Second Opinion: Patient can still get surgery if…

Answer 14

2 surgeons disagree with each other

Question 15

Physicians Expense Insurance

Answer 15

Pays for physician charges at hospitals, offices, etc.

Question 16

Physicians Expense Insurance capped at…

Answer 16

Certain dollar amount and/or number of visits

Question 17

Major Medical Insurance

Answer 17

Pays for hospital, surgical, and physician charges under the same policy

Question 18

MMI: Has high dollar limits but…

Answer 18

Cost-sharing

Question 19

MMI: HAs annual out-of-pocket limits per…

Answer 19

Year

Question 20

Major Medical Insurance was originally bought as…

Answer 20

Supplemental for basic expense policies

Question 21

MMI: After basic policies were exhausted, consumer…

Answer 21

Paid “corridor deductible” before major medical kicked in

Question 22

Major Medical Insurance is now bought…

Answer 22

Stand alone, with a deductible at the start

Question 23

Deductible

Answer 23

Amount of otherwise insured loss that must be paid out of pocket before benefits will kick in

Question 24

Deductible is typically…

Answer 24

Per year or per cause

Question 25

Per Cause

Answer 25

Might apply after 30 days of not needing similar care

Question 26

Per Calendar Year

Answer 26

Might allow for a "carryover provision" for amounts paid in last 3 months of previous year

Question 27

Family Deductible

Answer 27

Might prevent all members from having to meet their own deductible after a few members have met their own deductible

Question 28

Coinsurance

Answer 28

Splits the cost of medical bills on a percentage basis

Question 29

Common coinsurance percentage

Answer 29

80% by insurer, 20% by insured

Question 30

Coinsurance is applied...

Answer 30

After deductible is met

Question 31

Copayment

Answer 31

Paid by insured as a flat fee per service; often due at time of service

Question 32

Out of Pocket Limit

Answer 32

Caps the amount the insured must pay per year in coinsurance fees, deductibles, and sometimes copay

Question 33

Out of Pocket doesn't include...

Answer 33

Premiums or excluded care

Question 34

Stop Loss is the...

Answer 34

Out of pocket limit

Question 35

ACA Plans must have out of pocket limits for...

Answer 35

Essential health benefits

Question 36

Reimbursement Plan

Answer 36

Pay based on cost of care received

Question 37

Reimbursement plans typically involve reimbursing the policyholder rather than...

Answer 37

Paying the provider directly

Question 38

Reimbursement plans are typically sold by...

Answer 38

For-profit insurers

Question 39

Reimbursement plans typically don't emphasize a...

Answer 39

Network for providers

Question 40

Service Plans

Answer 40

Subscribers pay premiums for future medical services, not for reimbursement

Question 41

Service plans arrange for care options via a...

Answer 41

Network of physicians who either work for or have contracts with them

Question 42

BCBS is typically operated as a...

Answer 42

Non-profit service plan

Question 43

Managed Care Plans

Answer 43

Plans that attempt to control how care is provided in order to improve efficiency and reduce costs

Question 44

Pre-Authorization Requirements

Answer 44

Required before being admitted to facility

Question 45

Concurrent Review

Answer 45

Ensure prompt discharge from facility

Question 46

Managed Care Plans' coverage is typically...

Answer 46

Limited or no out-of-network coverage

Question 47

HMO stands for...

Answer 47

Health Maintenance Organization

Question 48

HMO: Has what level of managed care?

Answer 48

High level

Question 49

HMO: Has a close relationship between...

Answer 49

Plan and Physician

Question 50

HMO: Responsible for...

Answer 50

Paying and providing care

Question 51

HMO: Providers are paid...

Answer 51

Flat annual or monthly fee or per patient, not per service performed

Question 52

Capitation

Answer 52

Flat monthly or annual fee

Question 53

HMO: Primary care physician acts as a...

Answer 53

Gatekeeper for referrals to specialists

Question 54

HMO: All care must be provided by...

Answer 54

In-network providers, other than emergencies

Question 55

HMO: Emphasis on...

Answer 55

Preventive care

Question 56

HMO: Premiums are...

Answer 56

Low and has limited cost-sharing, emphasis on small copayments

Question 57

PPO stands for...

Answer 57

Preferred Provider Organization

Question 58

PPO: Has what level of managed care?

Answer 58

Moderate

Question 59

PPO: Contracts with physicians who provide care to subscribers at...

Answer 59

Reduced fee-for-service rate

Question 60

PPO: Covers in-network care at what amount? Covers out-of-network at what amount?

Answer 60

Higher; Lower

Question 61

PPO: For out-of-network emergency...

Answer 61

No reduction in benefits

Question 62

PPO: For specialists...

Answer 62

Often no primary care referral necessary

Question 63

POS stands for...

Answer 63

Point of Service

Question 64

POS: Like HMO, care is managed by...

Answer 64

Primary care physician

Question 65

POS: Like PPO, some coverage for...

Answer 65

Out-of-network care, though less coverage