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AZ Medical Plans

What is a Fee-for-Service Plan? Providers receive a payment for each individual service they provide to the insured.
Which is a Fee-for-Service Plan, a PPO or an HMO? A Preferred Provider Organization (PPO)
What is a Prepaid Plan? Providers are given payments whether or not they provide service to the insured or not.
A PPO or an HMO operates on a Prepaid basis? A Health Maintenance Organization
What is specified coverage? Coverage limited to one specific illness or one limited group of coverage's. Examples would be: cancer policy, prescription drug policy
Comprehensive care policies typically include what? preventive care, routine physicals, immunizations, outpatient services & hospitalizations.
An HMO is an example of a comprehensive care policy. TRUE or FALSE TRUE
What is a benefit schedule? states in the policy exactly what is covered and at what dollar amount.
The term usual/reasonable/customary refers to what? Insurer will provide coverage amount based on the average charge for that specific procedure in that particular geographic region.
The_______________ are the people who sign up for pre-paid health plans. They are also known as participants or members. Subscribers
What is major medical insurance designed to cover? Major medical insurance is designed to cover catastrophic loss by using coinsurance and deductibles.
Would major medical insurance respond to small, regular claims? No, major medical ins only responds to the infrequent large claims. Usually has high max benefits (1-2 million dollars).
A portion of payments required to be made by the insured each benefit period before the insured can receive benefit payments is known as __________________. Deductibles, the deductible amount is the portion of medical expenses that are paid by the insured each year before the insurance benefits start.
Name 6 exclusions found in major medical insurance policies. injuries caused by war, intentionally self-inflicted injuries, regular dental/vision/hearing care, custodial care, injuries covered by workman's compensation, cosmetic surgery
What is coinsurance used for? Coinsurance is used to share cost after the deductible has been met. Usually 80/20
What is a copayment? A copayment is a specific dollar amount paid by the insured for office visits.
Is a copayment a fixed dollar amount or a percent? Copayments are a fixed dollar amount
What is a stop-loss feature? Stop-loss feature: when the insured's out of pocket expenses reach a certain limit in a benefit period, the company will pay 100%. This does not include the deductible.
Name 4 things major medical expense contracts are characterized by. High maximum limits, blanket coverage, coinsurance & a deductible
What is the main goal of an HMO? provide preventative services to stop illness & injury from becoming too expensive.
HMOs usually have a geographically limited serviced area. TRUE or FALSE TRUE
Who chooses the Primary Care Physician? the insured
How does an insured with an HMO see a specialist? A primary care physician is responsible for making referrals to a specialist.
How can a physician be added to a PPO list? A physician can be added at any time by paying the appropriate fees & agreeing to the terms of service set out by the PPO
A primary care physician is also known as what? A gatekeeper
What is a point of service plan? combination of HMO & PPO
Type of plan that allows members to choose between plans as they need arises Point of service plan
What let physicians submit claim information PRIOR to a procedure to see if it is covered under the insured's plan Prospective review
Children dependents are covered until what age in Arizona? 26th birthday
In Arizona, when does coverage begin on a newborn child? immediately after birth
A medical caregiver that retains the right to treat patients who are not members or subscribers is referred to as open panel
If a PPO member chooses to see a medical provider that is not found on the preferred list will there be more or less of an out of pocket expense? more out of pocket expense
What are managed care plan designed to do? control costs by controlling the behavior of the plan participants
What would a physician use to detect medical problems before symptoms appear? Preventive care
List 4 essential benefits listed under the Affordable Health Care Act hospitalization, emergency services, wellness & preventative services, chronic disease management
Physically or mentally handicapped dependents can remain on parents insurance for how long? Indefinably
Three eligibility requirements for the Affordable Care Act U.S. citizen or national, live in the U.S., cannot be currently incarcerated
Metal level plans pay how: Bronze 60%, Silver 70%, Gold 80%, Platinum 90%
Created by: jgray2015