Health Plan Basics
What’s the term for the maximum you’ll pay in a year before insurance covers 100%?
Out-of-pocket maximum
When is Open Enrollment for individual health plans?
November 1 to January 15
Which account is "use it or lose it"?
FSA – Flexible Spending Account
What does HMO stand for?
Health Maintenance Organization.
What document summarizes what a plan covers and costs?
Summary of Benefits and Coverage – SBC.
What is the term for the portion of a covered health service the member must pay after the deductible is met?
Coinsurance.
What’s a Special Enrollment Period?
A time outside Open Enrollment when you can enroll due to a qualifying life event.
What is a limited-purpose FSA used for?
Dental and vision expenses only
What does PPO stand for?
Preferred Provider Organization.
What law requires employers to offer continuation of group health coverage after job loss?
COBRA.
What is the "Coordination of Benefits" process?
Determining which plan pays first when a member has coverage under multiple plans.
List two qualifying life events?
Examples: marriage, birth, loss of coverage.
What is a limited-purpose FSA used for?
Dental and vision expenses only
What type of plan allows out-of-network care and no referrals?
PPO.
What law protects employee medical privacy?
HIPAA.
What is balance billing and when is it typically allowed?
When a provider bills the member the difference between their charge and the allowed amount; allowed when out-of-network
Who sets Open Enrollment dates for group (employer) health plans?
The employer.
Who owns the money in an HSA account?
The employee
What kind of plan usually requires a PCP and referrals for specialists?
HMO.
Under HIPAA, what is the term for information that relates to an individual’s health status, provision of health care, or payment for health care?
Protected Health Information – PHI.
What is the term for a provider’s agreed-upon fee with an insurance carrier?
Negotiated Rate or Allowed Amount.
If an employee misses Open Enrollment and has no QLE, what happens?
They must wait until the next enrollment period.
Can an employee contribute to both an HSA and a general-purpose FSA?
No – IRS prohibits it unless the FSA is limited-purpose
What’s the main benefit of a High Deductible Health Plan (HDHP)?
Lower premiums, HSA eligibility.
What’s the name of the act that expanded access to individual health coverage and marketplaces?
Affordable Care Act – ACA