5-H Health Insurance

Shelly has been suffering from chronic headaches for over a year. She is sure that there is something medically wrong, despite what the doctors in her network have told her. So, she decides to visit a doctor that her friend recommended, even though he charges more and is not in Shelly's approved network. Shelly's insurer paid for the cost of the appointment up to the amount she would have reasonably been charged by an in-network physician, and Shelly was responsible for paying the remaining balance. Which type of health insurance plan does Shelly have? - Major Medical plan - Health Maintenance Organization - Preferred Provider Organization - Point of Service plan

- Preferred Provider Organization

Which of the following statements about Health Maintenance Organizations is FALSE? - An HMO will pay for both in-network care, but only up to the amount established by network providers. - An HMO establishes a network of care providers. - HMO's promote health and wellness programs for policyholders in order to curb healthcare costs. - An HMO assigns a primary physician to each policyholder.

An HMO will pay for both in-network care, but only up to the amount established by network providers. WHY: a PPO (not a HMO) will pay for both in-network and non-network care, but only up to the amount established by network providers. HMO members cannot select their own physicians, hospitals, or care providers outside the GMO network.

The healthy insurance contract also called the ______, spells out the exact provisions of a policyholder's health insurance coverage.

Evidence of Coverage WHY: What and how much the insurer will pay varies from policy to policy. The exact provisions of coverage are explained in the health insurance contract, often referred to as "Evidence of Coverage."

Which of the following insurance packages will indemnify a policyholder for variety of hospital-related expenses such as nursing care, supplies, and rooming charges? - Hospital expense insurance - Surgical expenses insurance - Accident insurance - Hospital indemnity insurance

Hospital expense insurance WHY: Hospitalization Expense insurance providers coverage for a variety hospital expenses, including room and board, medical expenses, lab fees, nursing care and other hospital fees.

Maria was in the hospital for five days, recovering from a stroke. The bill she received for hospital stay broke down the charges for room, lab fees, meals, and nursing care. However, her insurer paid a flat daily rate and she was left responsible for paying the remaining charges. What type of insurance does Maria have?

Hospital indemnity insurance WHY: Hospital Indemnity insurance is a supplemental coverage that provides a flat amount of indemnification per day for hospitalization.

A policyholder can expect the highest amount of coverage for medical care under which of the following plans? - Point of service plan - Preferred provider organization - Health maintenance organization - Major medical plan

Major medical plan WHY: Major Medical plans provide the highest amount of medical coverage.

Nick has a comprehensive individual health insurance policy that he purchased through an HMO, and Charity has a PPO plan through her employer. Which of the following statements is TRUE? - Nick has a higher level of flexibility in choosing his health care than Charity, but Charity has lower medical costs than Nick. - Nick's plan allows him to go to any hospital for emergency services, but Charity is restricted to approved hospitals within the network. - Nick's policy was automatically accepted by his insurer, but Charity had to prove her current health status before being accepted. - Nick was assigned a primary care physician who must coordinate his health care within a network, but Charity may choose a primary physician outside the network.

Nick was assigned a primary care physician who must coordinate his health care within a network, but Charity may choose a primary physician outside the network.

Which of the following statements regarding primary care physicians is FALSE? - Point of Service Plans allow a policyholder to select his own primary care physician. - Preferred Provider Organizations do not allow policyholders to choose a primary care physician. - Major Medical Plan policyholders can choose any primary care physician they'd like. - A primary care physician must approve all medical procedures for policyholders in a Health Maintenance Organization.

Preferred Provider Organizations do not allow policyholders to choose a primary care physician. WHY: Preferred Provider Organizations allow members to choose either in-network, or non-network primary care physicians.

Which of the following is NOT considered an "out-of-pocket expense" in health insurance? - Deductible - Copayment - Policy premiums - Coinsurance

Policy premiums WHY: Deductibles, copayments, and coinsurance are called out-of-pocket expenses. They make up the portion of medical expenses that the policyholder is responsible for paying.

Sarah suffers acute back pain. Not satisfied with the specialists in her own network, Sarah elects to see a back specialist outside her network established by her healthcare provider. Her healthcare provider pays the amount that the same appointment would reasonably have cost with an in-network specialist, and Sarah has to pay the additional costs out of her own pocket. Which type of healthcare provider does Sarah belong to?

Preferred Provider Organization WHY: Sarah is a member of Preferred Provider Organization (PPO). Physicians inside the network establish reasonable costs for network care, and if the members elect non-network care, the PPO will only pay up the amount established by network doctors.

Which of the following medical conditions would NOT be covered under the terms of typical Accident insurance contract? - A dislocated shoulder - A bum suffered in an explosion - A broken leg suffered in a skiing accident - The removal of a cancerous tumor.

The removal of a cancerous tumor. WHY: Diseases, such as cancer, are excluded from coverage in accident insurance.

Which of the following statements regarding health insurance is TRUE? - To be covered, members of an HMO must receive treatment for their medical conditions within the established network of healthcare providers. - An HMO is usually the most expensive group insurance provider. - As opposed to joining insurance plan, purchasing health insurance on an individual basis can save a consumer thousands of dollars a year. - Major Medical plans tend to be very restrictive regarding the selection of physicians

To be covered, members of an HMO must receive treatment for their medical conditions within the established network of healthcare providers. WHY: To be covered, members of an HMO must receive treatment for their medical conditions within the established network of healthcare providers.

Insurers often protect themselves from providing insurance to people who are already ill by inserting which type of clause into a health insurance contract? - Time limit on defenses xx - Grace period - Waiting period - Double indemnity

Waiting period WHY: Insurers often add a waiting period the time a policy is used and when the insured can collect benefits. This clause is used to prevent applicants and insureds from seeking health insurance only after they have become sick or injured.

Jim's health insurance policy states he is responsible for 10% of the total cost of his medical bills. This percentage might be referred to as a :

coinsurance payment WHY: Jim's health insurance policy requires a 10% coinsurance payment. This means he must pay 10% of his total health care expenses.

According to Lonnie's health insurance policy, she is responsible for paying 15% of all of her medical costs. This percentage is Lonnie's:

coinsurance payment.

Susan purchases a health insurance package. Looking it over, she realizes her policy requires to pay $20 out-of-pocket every time she uses the benefits of the policy. That $20 is Susan's:

copayment WHY: The copayment is the amount a policyholder must pay each time she accesses the benefits of a health insurance policy

Individuals CANNOT purchase comprehensive health or catastrophic health insurance plans:

through an Out-of-Pocket (OOP) plan WHY: There are two kinds of Individual Health Insurance plans: comprehensive health insurance and catastrophic health insurance. These can be purchased directly through an insurance provider, or also through an HMO, a PPO, or a Point of Service plan, known as a POS.