State the Definition
What does EHB stand for?
Essential Health Benefits
True
A list of doctors and hospitals that consumers generally must use to get coverage and lower out-of-pocket costs.
What is a network?
Health insurance companies, groups of hospitals, doctors, pharmacies, and other health care providers have distinct rates for healthcare services. True or False?
False, they contract together to make an agreed upon rate.
Susan has a son. Her husband's health insurance plan has a $1,000 deductible for the family each plan year. Susan's 8-year-old son requires a medical procedure that will cost $1,500. The family already paid $750 toward the deductible this year. Assuming that the service is covered by the health insurance plan, there are no copayments or coinsurance, and balance billing doesn't apply, what will Susan pay for her son's medical procedure?
She will pay $250 (the remaining balance of the deductible).
What are pre-existing conditions? Name two examples.
medical conditions (like asthma, back pain, diabetes, or cancer) that consumers had before the date their current health coverage became effective.
False; it can only be sent electronically if consented.
summarizes key features of a health plan, including covered benefits, cost-sharing provisions, and coverage limitations and exceptions.
What is a SBC?
What services are covered before you meet your deductible?
Preventive care and primary care services
Sammy has a prescription for a generic brand of adderall. It has a retail cost of $300 per month. Thanks to coinsurance, she only has to pay 20% out of pocket. What should she expect to pay every month?
$60/month
What is the difference between copayment and coinsurance?
copayment is a fixed amount consumers pay to health care providers for a covered health care service, usually at the time of service.
Coinsurance is a consumer's share of the cost of a covered health care service calculated as a percentage.
A person gets covered emergency services from an out-of-network provider or out-of-network emergency facility. True or False.
True
Amount that must be paid out of pocket to a health insurance company to maintain enrollment in a health insurance plan.
What is a premium?
Why might consumers have to pay the difference for a covered service?
It goes over the "allowed amount" for that service.
State the three tiers in a drug formulary.
first tier includes generic drugs with the lowest cost to consumers
second tier includes preferred brand-name drugs with a higher cost to consumers
third tier includes non-preferred brand-name drugs with the highest cost to consumers
What is balance billing? Give a brief example.
when providers bill consumers for the difference between the provider's charge and the amount allowed by the health plans. ex: service costs $100 but insurance can only cover $60, so the consumer is billed $40.
Health coverage is important because it helps consumers enroll in health insurance plans through the Marketplace and in turn increases enrollment for CHIP, Medicaid, or Medicare. (True or False)
False
amount consumers pay out-of-pocket for certain covered health care services before their health insurance plan begins to pay.
What is a deductible?
What regulation requires health plans and issuers to limit cost sharing to in network cost-sharing amounts and prohibits out-of-network providers, facilities, or providers of air ambulance services from billing individuals more than the applicable cost-sharing amounts in three main scenarios?
What is the No Surprises Act.
You meet someone concerned because they just paid out of pocket for a procedure they were sure was covered by insurance. What do you suggest they do?
Make a claim to their insurance company.
What is the difference between health insurance and health coverage?
health coverage is defined as payment or reimbursement for health care costs that consumers are legally entitled to when enrolled in health coverage programs
Health insurance is a contract that requires a health insurer or company to pay some or all of a consumer's health care costs in exchange for a premium.
Going to see out of network providers with a PPO plan is more expensive than an HMO plan. True or False.
False, HMOs do not cover out of network visits at all.
only pays for services performed by providers within their network.
What are HMOs (health maintenance organizations)?
What three scenarios must SBCs list the estimated cost of?
having a baby, managing type 2 diabetes, and emergency room treatment for a simple fracture
Name a scenario for when a copayment plan would be more beneficial than coinsurance.
When the retail price of the drug/service is exorbitant. A fixed price would be more affordable.