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AZ Medical Plans
| What is a Fee-for-Service Plan? | Providers receive a payment for each individual service they provide to the insured. |
| Which is a Fee-for-Service Plan, a PPO or an HMO? | A Preferred Provider Organization (PPO) |
| What is a Prepaid Plan? | Providers are given payments whether or not they provide service to the insured or not. |
| A PPO or an HMO operates on a Prepaid basis? | A Health Maintenance Organization |
| What is specified coverage? | Coverage limited to one specific illness or one limited group of coverage's. Examples would be: cancer policy, prescription drug policy |
| Comprehensive care policies typically include what? | preventive care, routine physicals, immunizations, outpatient services & hospitalizations. |
| An HMO is an example of a comprehensive care policy. TRUE or FALSE | TRUE |
| What is a benefit schedule? | states in the policy exactly what is covered and at what dollar amount. |
| The term usual/reasonable/customary refers to what? | Insurer will provide coverage amount based on the average charge for that specific procedure in that particular geographic region. |
| The_______________ are the people who sign up for pre-paid health plans. They are also known as participants or members. | Subscribers |
| What is major medical insurance designed to cover? | Major medical insurance is designed to cover catastrophic loss by using coinsurance and deductibles. |
| Would major medical insurance respond to small, regular claims? | No, major medical ins only responds to the infrequent large claims. Usually has high max benefits (1-2 million dollars). |
| A portion of payments required to be made by the insured each benefit period before the insured can receive benefit payments is known as __________________. | Deductibles, the deductible amount is the portion of medical expenses that are paid by the insured each year before the insurance benefits start. |
| Name 6 exclusions found in major medical insurance policies. | injuries caused by war, intentionally self-inflicted injuries, regular dental/vision/hearing care, custodial care, injuries covered by workman's compensation, cosmetic surgery |
| What is coinsurance used for? | Coinsurance is used to share cost after the deductible has been met. Usually 80/20 |
| What is a copayment? | A copayment is a specific dollar amount paid by the insured for office visits. |
| Is a copayment a fixed dollar amount or a percent? | Copayments are a fixed dollar amount |
| What is a stop-loss feature? | Stop-loss feature: when the insured's out of pocket expenses reach a certain limit in a benefit period, the company will pay 100%. This does not include the deductible. |
| Name 4 things major medical expense contracts are characterized by. | High maximum limits, blanket coverage, coinsurance & a deductible |
| What is the main goal of an HMO? | provide preventative services to stop illness & injury from becoming too expensive. |
| HMOs usually have a geographically limited serviced area. TRUE or FALSE | TRUE |
| Who chooses the Primary Care Physician? | the insured |
| How does an insured with an HMO see a specialist? | A primary care physician is responsible for making referrals to a specialist. |
| How can a physician be added to a PPO list? | A physician can be added at any time by paying the appropriate fees & agreeing to the terms of service set out by the PPO |
| A primary care physician is also known as what? | A gatekeeper |
| What is a point of service plan? | combination of HMO & PPO |
| Type of plan that allows members to choose between plans as they need arises | Point of service plan |
| What let physicians submit claim information PRIOR to a procedure to see if it is covered under the insured's plan | Prospective review |
| Children dependents are covered until what age in Arizona? | 26th birthday |
| In Arizona, when does coverage begin on a newborn child? | immediately after birth |
| A medical caregiver that retains the right to treat patients who are not members or subscribers is referred to as | open panel |
| If a PPO member chooses to see a medical provider that is not found on the preferred list will there be more or less of an out of pocket expense? | more out of pocket expense |
| What are managed care plan designed to do? | control costs by controlling the behavior of the plan participants |
| What would a physician use to detect medical problems before symptoms appear? | Preventive care |
| List 4 essential benefits listed under the Affordable Health Care Act | hospitalization, emergency services, wellness & preventative services, chronic disease management |
| Physically or mentally handicapped dependents can remain on parents insurance for how long? | Indefinably |
| Three eligibility requirements for the Affordable Care Act | U.S. citizen or national, live in the U.S., cannot be currently incarcerated |
| Metal level plans pay how: | Bronze 60%, Silver 70%, Gold 80%, Platinum 90% |
Created by:
jgray2015
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