Healthcare Plans and Concepts Flashcards
the terms “usual, customary, and reasonable” refer to which of the following?
A
The average charge for a medical procedure, treatment, or service in a defined geographical area
B
A non-physician’s evaluation and approval of a medical procedure recommended by a patient’s physician or surgeon
C
The most commonly performed operations or treatments in a given territory
D
The standard accepted medical procedure for a given illness or injury
A -
The average charge for a medical procedure, treatment, or service in a defined geographical area
Managed health care plans generally refer to covered persons as ____________.
A
Beneficiaries
B
Subscribers
C
Insureds
D
Providers
B
Subscribers
HMOs usually require patients to select a ___________ as the person who will oversee and direct their basic health care in most cases.
A
Medical social worker
B
Care coordinator
C
Primary Care Physician
D
Insurance agent or broker
C
Primary Care Physician
All of the following are differences between a PPO plan and an HMO, EXCEPT:
A
Providers charge a discounted fee negotiated in advance
B
Use of a Primary Care Physician
C
Freedom to choose any service provider
D
It is a managed care plan
D
It is a managed care plan
Basic health plans provide “first dollar” coverage, which means:
A
The beneficiary of an insured must pay the first dollar of expenses if an insured dies prior to paying the claim
B
Benefits are payable starting with the first dollar of expenses incurred up to a stated maximum benefit and without a deductible
C
The insured must pay a deductible first before the insurer will pay any benefits
D
The insurance company pays 100% of all claims and the insured has no out-of-pocket expenses
B
Benefits are payable starting with the first dollar of expenses incurred up to a stated maximum benefit and without a deductible
An insured is covered under a major medical plan with a $500 deductible that has not been paid and 80/20 coinsurance requirement. A minor injury is suffered and the total covered cost for treatment is $1,500. How much will the insurance company cover?
A
$700
B
$500
C
$1,200
D
$800
D
$800
Newborn children are covered under medical expense plans beginning ___________.
A
On the 31st day following birth
B
On the 14th day following birth
C
On the 15th day following birth
D
Immediately at birth and for at least 31 days
D
Immediately at birth and for at least 31 days
A High Deductible Health Plan is a:
A
Health plan offered by large companies who are trying to minimize the growing cost of providing employee health insurance
B
Health plan which requires the insured to absorb a relatively high deductible in exchange for a significantly reduced premium
C
Health Maintenance Organization established to provide comprehensive medical services on a prepaid basis
D
Basic medical expense plan which pays first dollar expenses
B
Health plan which requires the insured to absorb a relatively high deductible in exchange for a significantly reduced premium
A flexible spending account can only be opened if:
A
A qualified long-term care coverage is purchased
B
The insured is self-employed
C
Offered through an employer-established benefit plan
D
A High Deductible Health Plan is purchased
C
Offered through an employer-established benefit plan
An insured covered under a $1 million accidental death and dismemberment policy is involved in an accident that resulted in the loss of both legs 3 days after the accident. Following a lengthy hospital stay, her losses included $300,000 in medical bills, $100,000 in hospital expenses, and $10,000 in loss of income due to her inability to work. Which of the following is payable from the AD&D policy?
A
$410,000 for medical expense, hospital expense, and loss of income and $500,000 for the dismemberment
B
The capital sum of $500,000 for dismemberment
C
Medical expense reimbursement of $300,000
D
The principal sum of $1 million for double dismemberment
D
The principal sum of $1 million for double dismemberment
A typical hospital indemnity insurance plan provides payment of benefits in which of the following ways?
A
An amount equal to the insured’s deductible and coinsurance amounts
B
A percentage of benefits based on a written schedule of common procedures and treatments
C
As reimbursement for usual, customary and reasonable necessary medical expenses paid by the insured
D
A daily benefit based on a stated dollar amount paid to the insured without regard to the actual medical expenses
D
A daily benefit based on a stated dollar amount paid to the insured without regard to the actual medical expenses
All of the following are characteristics of dental insurance plans, EXCEPT:
A
Orthodontic care is covered immediately following the effective date of the policy
B
Purely cosmetic services are excluded from coverage
C
Deductibles and coinsurance generally apply to basic and major services
D
Cleaning and x-rays are preventive care services
A
Orthodontic care is covered immediately following the effective date of the policy
orthodontic care is provided, a probationary period typically applies and benefits are reduced for a stated period of time.
Which of the following types of coverage has a corridor deductible?
A
Major medical
B
Basic medical expense
C
Comprehensive major medical
D
Supplemental major medical
D
Supplemental major medical
All of the following are qualified medical expenses for Heath Savings Accounts, except:
A
Diagnostic charges
B
Vitamins
C
Prescriptions
D
Medical supplies
B
Vitamins
For what type of provider are services covered in or out of a network by a combination of a PPO and/or an HMO?
A
MPP
B
PPO
C
ASO
D
POS
D
POS
