MP1
What is the role of the gatekeeper in an HMO plan?
To control costs for the services of specialists
What type of health insurance plans cover all accidents and sicknesses that are not specifically excluded in the policy?
Who chooses a primary care physician in an HMO plan?
The individual memeber
How are HMO territories typically divided?
Geographic areas
What types of injuries and services will be excluded from major medical coverage?
Injuries caused by war, intentionally self-inflicted injuries, injuries covered by worker compensation, regular dental/vision/hearing care, custodial care and elective cosmetic surgery
What are the three types of basic medical expense insurance?
Hospital, surgical and medical
What is a fee for service health plan?
Under a fee for service plan, providers receive payments for each service provided
How can an HMO member see a specialist?
Referral by the primary care physician
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 are two types of Flexible Spending Accounts?
Health Care Accounts and Dependent Care Accounts
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 managed care health insurance plans?
To control health insurance claims expenses
What is the main principle of an HMO plan?
Preventive care
What is the main difference between coinsurance and copay?
Copay is a set dollar amount, coinsurance is a percentage of the expenses
When are newborns covered in individual health insurance policies?
From the moment of birth
What are usual/reasonable and customary charges based on?
Average charge for a given procedure in the specific geographic area
What are the tax implications for contributions to a Health Savings Accounts by the individual insured?
Contributions are tax deductible
Why do HMO's encourage members to get regular checkups?
To help catch health problems early when treatment has the greatest chance for success (ie. preventive care)
In what type of health plans are providers paid for services in advance, regardless of the services provided?
Prepaid plans
What provision provides for the sharing of expenses between the insured and the insurance company?
Coinsurance
What is the purpose of the coinsurance provision in health insurance policies?
To prevent over utilization of the policy benefits
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