Chapter 10 Flash Cards

Why do HMOs encourage members to get regular checkups?

To help catch health problems early when treatment has the greatest chance for success (i.e. preventive care)

How can an HMO member see a specialist?

Referral by the primary care physician

When are newborns covered in individual health insurance policies?

From the moment of birth

What are the tax implications for contributions to a Health Savings Accounts by the individual insured?

Contributions are tax deductible

What is the main principle of an HMO plan?

Preventive care

What types of injuries and services will be excluded from major medical coverage?

Injuries caused by war, intentionally self-inflicted injuries, injuries covered by workers compensation, regular dental/vision/hearing care, custodial care, and elective cosmetic surgery

Who chooses a primary care physician in an HMO plan?

The individual member

What is the role of the gatekeeper in an HMO plan?

To control costs for the services of specialists

What are the two types of Flexible Spending Accounts?

Health care accounts and dependent care accounts

What is a fee-for-service health plan?

Under a fee-for-service plan, providers receive payments for each service provided

What is the purpose of managed care health insurance plans?

To control health insurance claims expenses

In what type of health plans are providers paid for services in advance, regardless of the services provided?

Prepaid plans

Can an insured who belongs to a POS plan use an out-of-network physician?

Yes, but the copays and deductibles may be higher

What is the purpose of the coinsurance provision in health insurance policies?

To prevent overutilization of the policy benefits

How are HMO territories typically divided?

Geographic areas

What are usual/reasonable and customary charges based on?

Average charge for a given procedure in the specific geographic area

What type of health insurance plans cover all accidents and sicknesses that are not specifically excluded in the policy?

Comprehensive plans

What are the five basic characteristics of managed care plans?

Controlled access to providers, comprehensive case management, preventive care, risk sharing, and high quality care

What is the main difference between coinsurance and copay?

Copay is a set dollar amount; coinsurance is a percentage of the expenses

What are the three types of basic medical expense insurance?

Hospital, surgical and medical

Under what type of care do insurers negotiate contracts with health care providers to allow subscribers access to health care services at a favorable cost?

Preferred Provider Organization (PPO)

What provision provides for the sharing of expenses between the insured and the insurance company?

Coinsurance