#1
What is a deductible in health insurance?
The amount the insured must pay out-of-pocket before the insurance company pays for covered services.
ExplanationInitial out-of-pocket payment by the insured before insurance coverage kicks in.
#2
Which of the following is not a type of managed care organization (MCO)?
Fee-for-Service Plan (FFS)
ExplanationNon-managed care plan where payment is made for services rendered, not pre-negotiated.
#3
Which federal law requires group health plans to provide a notice of privacy practices to individuals?
Health Insurance Portability and Accountability Act (HIPAA)
ExplanationLegislation mandating privacy practices notice in group health plans.
#4
Which of the following is not a factor typically considered when determining health insurance premiums?
Ethnicity
ExplanationEthnicity is not a typical factor in determining health insurance premiums.
#5
Which of the following is not typically covered by health insurance?
Cosmetic surgery
ExplanationCosmetic surgery is typically not covered by health insurance.
#6
Which of the following statements best describes a copayment (copay)?
A fixed amount paid by the insured for covered services at the time of service.
ExplanationFixed amount paid by insured at the time of service for covered services.
#7
What is 'capitation' in the context of managed care?
A system where providers are paid a fixed amount per patient enrolled, regardless of the services provided.
ExplanationFixed payment per patient, irrespective of actual services rendered.
#8
Which federal program provides health insurance coverage for individuals aged 65 and older?
Medicare
ExplanationGovernment program providing health coverage for individuals aged 65 and older.
#9
What is the main purpose of utilization management in managed care?
To minimize unnecessary healthcare services and control costs.
ExplanationManagement strategy to reduce unnecessary healthcare services and manage costs.
#10
Which of the following statements best describes a Health Savings Account (HSA)?
A tax-advantaged account that individuals can use to pay for qualified medical expenses.
ExplanationTax-advantaged account for medical expenses payment.
#11
Which of the following is a characteristic of a High Deductible Health Plan (HDHP)?
It allows individuals to contribute pre-tax dollars to a Health Savings Account (HSA).
ExplanationEnables pre-tax contributions to a Health Savings Account.
#12
What is a health maintenance organization (HMO) gatekeeper?
A primary care physician responsible for coordinating and managing a patient's care.
ExplanationPrimary care physician managing and coordinating patient care in HMOs.
#13
What is 'co-insurance' in health insurance?
A percentage of covered expenses that the insured must pay after reaching the deductible.
ExplanationPercentage of expenses paid by the insured after reaching deductible.
#14
What is 'prior authorization' in the context of health insurance?
A requirement for patients to seek approval from their insurance company before certain services are covered.
ExplanationApproval needed from insurance before certain services are covered.
#15
What is 'medical underwriting' in the context of health insurance?
A process of evaluating an individual's health status to determine eligibility and premiums.
ExplanationAssessment of health status for insurance eligibility and premium determination.
#16
What is a health reimbursement arrangement (HRA)?
A tax-advantaged account funded by an employer to reimburse employees for qualified medical expenses.
ExplanationEmployer-funded account for reimbursing employees' medical expenses.
#17
What is 'balance billing' in the context of health insurance?
A billing method used by healthcare providers to charge patients for the remaining balance after insurance reimbursement.
ExplanationBilling method charging patients for remaining balance post-insurance reimbursement.
#18
What is 'adverse selection' in the context of health insurance?
A situation where individuals with lower healthcare needs are more likely to enroll in insurance plans.
ExplanationTendency for those with lower healthcare needs to enroll in insurance plans.
#19
What is the purpose of coordination of benefits (COB) in health insurance?
To prevent individuals from receiving duplicate payments for the same medical expenses.
ExplanationPrevents duplicate payments for the same medical expenses in COB.