Module 3

Question 1

The portion of health care costs paid by the participant during the plan year before the health plan begins to pay

Answer 1

Deductible

Question 2

The participant’s share of the cost of medical services

Answer 2

Coinsurance

Question 3

A fixed amount paid by the participant for a health care service

Answer 3

Copay

Question 4

A specific healthcare provider that manages the care of the participant

Answer 4

Primary care provider

Question 5

Authorization from a PCP to receive medical care from another provider, often a specialist

Answer 5

Referral

Question 6

The process when insurance makes a victim whole after a loss

Answer 6

Indemnification

Question 7

The maximum a covered individual will pay during a plan year before the health plan pays 100% of the costs of service

Answer 7

Out-of-pocket maximum

Question 8

This is also known as the allowed amount, eligible expense, payment allowance, or negotiated rate. It is generally the basic cost of a service in a geographic area.

Answer 8

Usual, customary, or reasonable (UCR) fee

Question 9

Immunizations, well-woman checks, cholesterol screenings, and teeth cleanings are what type of care?

Answer 9

Preventative

Question 10

Independent organizations or affiliates of health insurance carriers or health provider organizations specializing in behavioral health

Answer 10

MBHOs

Question 11

Employment-based medical plans that cover a percentage of losses for hospital, diagnostic, and physician services expenses

Answer 11

Indemnity plans

Question 12

Traditional, fee-for-service, and conventional plans are also known as ____________.

Answer 12

Indemnity plans

Question 13

A type of plan where the insurance carrier has a significant role in the oversight of health services and care.

Answer 13

Managed care

Question 14

A type of plan where the participant must select a primary care physician from a set network of providers who will act as a gatekeeper to all services.

Answer 14

HMO

Question 15

A type of plan that allows for limited out-of-network services that are not dependent on a physician referral

Answer 15

PPO

Question 16

A hybrid managed care plan that combines the HMO and PPO models. It offers in- and out-of- network access and requires a primary care provider.

Answer 16

Point of service

Question 17

This type of plan focuses more on catastrophic insurance and typically has a lower premium cost and a higher deductible.

Answer 17

HDHP

Question 18

Healthcare savings plan that allows the election of a certain dollar amount (up to IRS limits made at the beginning of the plan year that will be payroll deducted on a pre-tax basis from one’s paycheck)

Answer 18

FSA

Question 19

Employer-funded health savings accounts where the employer does not have to roll over unused contributions from year to year.

Answer 19

HRA

Question 20

A health savings plan that can be funded by the employer and employee. Funds can be rolled over from year to year and are portable in the event employees leave the company.

Answer 20

HSA

Question 21

A rule requiring employers to offer health insurance to full-time employees as defined under the ACA or pay a penalty

Answer 21

Play-or-pay mandate

Question 22

A method of healthcare reimbursement to providers paid on a per-beneficiary basis

Answer 22

Capitation

Question 23

A method of healthcare reimbursement to providers paid on a per-recipient basis

Answer 23

Contact capitation

Question 24

A method of healthcare reimbursement to providers paid on a per-episode basis, which can be based on diagnosis-related groups

Answer 24

Bundled payments

Question 25

A method of healthcare reimbursement to providers paid on a per-service basis

Answer 25

Fee for service

Question 26

Comprehensive protections against surprise medical
bills from out-of-network
providers for emergency services/nonemergency services at in-network facilities

Answer 26

No Surprises Act

Question 27

Agreements that restrict or prevent insurers
from making price or quality information available to patients or other third parties

Answer 27

Gag clauses

Question 28

Coverage for mammograms & colonoscopies
must be provided by group health plans subject to the ACA mandates without
charging a deductible, copay, or coinsurance

Answer 28

Expansion of preventive services