Medical And Dental Plans

Question 1

Major Medical Ins is considered to be what type of plan

Answer 1

Comprehensive

Question 2

Purpose of preadmission certification

Answer 2

Eliminate unnecessary treatment thereby lowering premiums

Question 3

Medical expense policies cover a newborn from when?

Answer 3

The moment of birth

Question 4

On medical expense ins, what is the most benefit the insurer will pay?

Answer 4

Scheduled benefit limit

Question 5

Health Care Service Org can be used in place of what term?

Answer 5

Health Maintenance Organization or HMO

Question 6

HMO primary care doc serves as what between members and health care providers?

Answer 6

Gatekeeper. Primary care doc makes referrals, authorizes treatment, and provides general care

Question 7

What do Healthcare Service Orgs stress/encourage?

Answer 7

Preventative care

Question 8

HCSOs pay reimbursements to who?

Answer 8

to providers directly - not to insureds

Question 9

Group Practice Model

Answer 9

Doc works in an independent group clinic on behalf of an HCSO

Question 10

HMO primary care docs DONT include who?

Answer 10

Internists

Question 11

HMO primary care docs include who

Answer 11

family practice, pediatrics, obstetrics and gynecology

Question 12

Do HMOs cover adult hearing tests as preventative care?

Answer 12

Usually No

Question 13

HMO services must be provided in network except for

Answer 13

Emergencies

Question 14

Managed Care does not include what type of plan

Answer 14

Indemnity plans

Question 15

Managed care includes services provided by who

Answer 15

HMOs, PPOs, and Point of Service POS

Question 16

Medical expense claims are often paid on what basis?

Answer 16

Fee for service

Question 17

Major Medical Expense Policies have what deductible (how long)

Answer 17

Comprehensive Calendar Year

Question 18

What is the difference between concurrent review and pre-certification in utilization management?

Answer 18

Pre-certification is done prior to treatment

Question 19

What does a stop loss feature do on a major medical policy

Answer 19

Limits the amount of coinsurance the insured has to pay on a large claim

Question 20

Major medical expense policies are usually written as what, cancellable or noncancellable

Answer 20

Cancellable, the company can cancel at any time as long as it gives advance notice

Question 21

Medical expense policies have a probationary period, what does it apply to

Answer 21

Applies to pre existing conditions meaning they won’t be covered if it occurs during the probationary period

Question 22

What does a family deductible do

Answer 22

Limits the total amount the family must pay during the year no matter how many family members get sick

Question 23

Assignment of benefits on medical expense insurance does what

Answer 23

Allows the insurer to pay benefits directly to the provider

Question 24

What do you subtract first when calculating how much the company will pay on a claim?

Answer 24

Subtract the deductible first then apply the coinsurance percentage

Question 25

What happens when PPO subscribers go to out of network providers?

Answer 25

They’ll receive reduced benefits

Question 26

If you have a POS plan, what happens if you go out of network?

Answer 26

Higher deductibles

Question 27

On medical expense plans, a mandatory second opinion results in what

Answer 27

Fewer claims

Question 28

Carryover deductible applies to what

Answer 28

Claims that occur during the last 3 months of the calendar year. They carry over and apply to next years deductible

Question 29

If an insurer wants to stress preventative care, what should they do regarding the deductible?

Answer 29

Waive it

Question 30

In dental plans, what would cause adverse selection?

Answer 30

Offering more than one open enrollment period

Question 31

How are dental policies written in order to prevent against adverse selection?

Answer 31

As a group policy

Question 32

Does dental insurance have a deductible on diagnostic or preventative care?

Answer 32

No

Question 33

Dental insurance covers restorative care what does that include

Answer 33

Fillings inlays and crowns

Question 34

What does endodonic include

Answer 34

Root canals

Question 35

What is periodontics

Answer 35

Gum problems

Question 36

What does bridgework fall under

Answer 36

Prosthodontics

Question 37

How can you satisfy the deductible on a integrated medical/dental plan

Answer 37

Either medical or dental expenses

Question 38

Dental indemnity plans are written how

Answer 38

Scheduled (basic) or nonscheduled (comprehensive)

Question 39

Comprehensive dental plans are similar to major medical expense plans in what way

Answer 39

They have a deductible and coinsurance

Question 40

Dental insurance may be written in the same manner as an HMO how

Answer 40

It can be written as a prepaid service plan

Question 41

Do dental insurance plans cover cosmetic dentistry?

Answer 41

No

Question 42

Basic dental plans have first dollar coverage meaning

Answer 42

No deductible no coinsurance