Benefits Basics
What is a PPO?
A plan that allows members to see both in-network and out-of-network providers.
Name three qualifying life events.
Marriage, divorce, birth/adoption, loss of coverage, death of a dependent.
Name 3 common medical carriers.
UnitedHealthcare, Aetna, Cigna, Blue Cross Blue Shield, Kaiser.
What is preventive care?
Covered services intended to prevent illness, such as annual physicals and screenings.
If you pass the person in second place during a race, what place are you in?
Second place
An employee is enrolled in employee-only coverage but gets married during the year. What must occur before they can add their spouse?
They must experience a qualifying life event and submit the required documentation within the allowed timeframe.
How many days do most employees have to report a qualifying life event?
Question: Typically 30 days (depending on employer plan rules).
Why is staying in-network important?
Lower costs and higher coverage levels.
A member's deductible is $2,000. They've met $1,250 and receive a covered service costing $1,000. How much of the service will apply to the deductible?
$750
What is the largest organ in the human body?
The skin
A member has already met their deductible and owes 20% of a $2,000 covered claim. How much will the member owe?
$400
Who can usually be covered as a dependent?
A spouse and eligible children.
What can happen if prior authorization is not obtained when required?
Claims may be denied or paid at a reduced benefit.
A EE has a $3,000 out-of-pocket maximum. They have already paid $2,800 toward it and receive a covered service that normally would leave them with $500 in coinsurance. How much will they actually pay?
$200
What is SpongeBob's job?
A fry cook
What does HMO stand for?
Health Maintenance Organization.
An employee's child loses coverage under another plan and needs benefits through the employee's plan. What type of event may allow enrollment outside Open Enrollment?
What is a loss of other coverage qualifying life event?
Before scheduling surgery, what should a member check with their carrier?
If prior authorization is required.
A member receives an annual physical at no cost. During the visit, they discuss a new medical concern and additional testing is ordered. Why may they receive a bill?
The visit may have been processed as diagnostic rather than preventive?
What is the name of Mickey Mouse's dog?
What is Pluto.
A member asks why they still received a bill after meeting their deductible. Name one possible reason.
They may still owe coinsurance, copays, non-covered expenses, or out-of-network charges?
An employee had family coverage and gives birth to a child. They assume the baby is automatically enrolled and never submit paperwork. What is the potential issue?
The child may not be enrolled if required enrollment forms and documentation are not submitted within the plan's deadline?
A member sees an in-network facility, but one provider involved in their care is out-of-network. What issue could result?
An out-of-network charge or balance bill
A member asks which amount is applied toward the deductible: the provider's billed charge or the carrier's allowed amount?
The carrier's allowed amount
How many hearts does an octopus have?
3