Chapter 2: Introduction to Health Insurance and Managed Care
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Welcome back to Dr. Erickson's office. In your position here, you communicate with patients about their insurance benefits every day. You are responsible for obtaining accurate insurance information from patients and explaining fees for their health care. As you review the following scenarios, consider the importance of understanding basic health insurance terminology.
1a. A patient states, "I haven't met my deductible yet, and I'm afraid that this procedure will cost a lot." What does the patient mean?
a. The patient doesn't have insurance.
b. The patient hasn't paid their copayment.
c. The patient doesn't have the funds to pay for the procedure.
d. The patient hasn't paid the necessary amount for health care before the insurance company will pay.
1a. A patient states, "I haven't met my deductible yet, and I'm afraid that this procedure will cost a lot." What does the patient mean?
a. The patient doesn't have insurance.
b. The patient hasn't paid their copayment.
c. The patient doesn't have the funds to pay for the procedure.
d. The patient hasn't paid the necessary amount for health care before the insurance company will pay.
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Welcome back to Dr. Erickson's office. In your position here, you communicate with patients about their insurance benefits every day. You are responsible for obtaining accurate insurance information from patients and explaining fees for their health care. As you review the following scenarios, consider the importance of understanding basic health insurance terminology.
1a. A patient states, "I haven't met my deductible yet, and I'm afraid that this procedure will cost a lot." What does the patient mean?
a. The patient doesn't have insurance.
b. The patient hasn't paid their copayment.
c. The patient doesn't have the funds to pay for the procedure.
d. The patient hasn't paid the necessary amount for health care before the insurance company will pay.
1a. A patient states, "I haven't met my deductible yet, and I'm afraid that this procedure will cost a lot." What does the patient mean?
a. The patient doesn't have insurance.
b. The patient hasn't paid their copayment.
c. The patient doesn't have the funds to pay for the procedure.
d. The patient hasn't paid the necessary amount for health care before the insurance company will pay.
d. the patient hasn't paid the necessary amount for health care before the insurance company will pay.
1b. You request a $30 copayment from the patient. The patient asks what a copayment is. What do you say?
a. "A copayment is a percentage of the cost of the visit."
b. "A copayment is the total amount due for your visit."
c. "A copayment is a specific dollar amount you must pay for each visit or service received."
d. "A copayment is the amount our office charges for each visit."
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a. "A copayment is a percentage of the cost of the visit."
b. "A copayment is the total amount due for your visit."
c. "A copayment is a specific dollar amount you must pay for each visit or service received."
d. "A copayment is the amount our office charges for each visit."
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c. "A copayment is a specific dollar amount you must pay for each visit or service received."
1c. A patient calls to schedule an appointment for themself. While obtaining their health insurance information, you ask who the policyholder is. They state, "I'm not sure, my spouse or me, I guess." What do you say next?
a. "The policyholder is the person that selected the health insurance policy. Would that be you or your spouse?"
b. "The policyholder is the person who has signed a contract with the health insurance company and owns the health insurance policy. Would that be you or your spouse?"
c. "The policyholder is the person who is receiving health care and who is covered by the health insurance plan. I will list you as the policyholder."
d. "Thank you. I will list you both as the policyholder."
a. "The policyholder is the person that selected the health insurance policy. Would that be you or your spouse?"
b. "The policyholder is the person who has signed a contract with the health insurance company and owns the health insurance policy. Would that be you or your spouse?"
c. "The policyholder is the person who is receiving health care and who is covered by the health insurance plan. I will list you as the policyholder."
d. "Thank you. I will list you both as the policyholder."
b. "The policyholder is the person who has signed a contract with the health insurance company that owns the health insurance policy. Would that be you or your spouse?"
1d. Select all that apply. River says they recently became insured through insurance offered at their employer. River is the:
a. enrollee.
b. policyholder.
c. subscriber.
d. insured.
a. enrollee.
b. policyholder.
c. subscriber.
d. insured.
all of the above
2a. Review the following definitions and select the appropriate term for each.
a. Primary care provider who is responsible for supervising and coordinating healthcare services: ____
b. Method of financing managed care, where providers accept pre-established payments for a length of time: ___
c. Formal prior approval for an MCO for a patient to have a procedure done: ____
d. A request for a member to receive treatment from another provider: ____
a. Primary care provider who is responsible for supervising and coordinating healthcare services: ____
b. Method of financing managed care, where providers accept pre-established payments for a length of time: ___
c. Formal prior approval for an MCO for a patient to have a procedure done: ____
d. A request for a member to receive treatment from another provider: ____
a. gatekeeper
b. capitation
c. preauthorization
d. referral
b. capitation
c. preauthorization
d. referral
2b. Review the following definitions and select the appropriate term for each.
a. A fee paid by the patient to the provider at the time of service: ___
b. Amount the insured must pay before insurance will provide coverage: ___
c. The amount an insurance policyholder must pay to maintain insurance coverage: ___
d. Percentage the patient pays for covered services after the deductible has been met: ___
a. A fee paid by the patient to the provider at the time of service: ___
b. Amount the insured must pay before insurance will provide coverage: ___
c. The amount an insurance policyholder must pay to maintain insurance coverage: ___
d. Percentage the patient pays for covered services after the deductible has been met: ___
a. copayment
b. deductible
c. premium
d. coinsurance
b. deductible
c. premium
d. coinsurance
Emmerson has a parent who was permanently disabled due to an injury that was related to their service in the US Navy. What healthcare coverage would Emmerson be eligible for?
a. Civilian Health and Medical Program of the Department of Veteran Affairs (CHAMPVA)
b. Veteran's Association (VA)
c. Competitive medical plan (CMP)
d. TRICARE
a. Civilian Health and Medical Program of the Department of Veteran Affairs (CHAMPVA)
b. Veteran's Association (VA)
c. Competitive medical plan (CMP)
d. TRICARE
a. Civilian Health and Medical Program of the Department of Veteran Affairs (CHAMPVA)
Dakota is 67 and recently retired. Upon retirement, they lost their group health insurance. Dakota is now eligible for ____, which will provide health care due to their age.
a. Medicare
b. COBRA
c. Social Security
d. Medicaid
a. Medicare
b. COBRA
c. Social Security
d. Medicaid
a. medicare
a. Provided lower costs of Medicare premiums and deductibles to benefit-eligible beneficiaries: ___
b. Provided funding for construction, renovation, and equipment to acquire health information technology systems: ___
c. Established an Office of the National Coordinator for Health Information Technology within HHS to improve health care quality, safety, and efficiency: ___
d. Provides quality affordable health care for Americans, improves the role of public programs and the quality and efficiency of health care, and improves public health: ___
e. Implemented health care reform initiatives such as increased tax credits for health care insurance, closed the Medicare "donut hole," and modified higher education assistance provisions: ___
b. Provided funding for construction, renovation, and equipment to acquire health information technology systems: ___
c. Established an Office of the National Coordinator for Health Information Technology within HHS to improve health care quality, safety, and efficiency: ___
d. Provides quality affordable health care for Americans, improves the role of public programs and the quality and efficiency of health care, and improves public health: ___
e. Implemented health care reform initiatives such as increased tax credits for health care insurance, closed the Medicare "donut hole," and modified higher education assistance provisions: ___
a. Medicare Improvement for Patient's and Provider's Act (MIPPA)
b. American Recovery and Reinvestment Act of 2009 (ARRA)
c. Health Information Technology for Economic and Clinical Health Act (HITECH Act)
d. Patient Protection and Affordable Care Act (PPACA)
e. Health Care and Education Reconciliation Act (HCERA)
b. American Recovery and Reinvestment Act of 2009 (ARRA)
c. Health Information Technology for Economic and Clinical Health Act (HITECH Act)
d. Patient Protection and Affordable Care Act (PPACA)
e. Health Care and Education Reconciliation Act (HCERA)
A. Protection and compensation for railroad workers injured on the job: ___
B. Provides federal government civilian employees with medical care, survivors' benefits, and compensation for lost wages: ___
C. Provides federal grants to modernize hospitals that became obsolete during the Great Depression and World War II due to a lack of funds: ___
D. Provides federal employees, retirees, and their survivors with health plans that meet their needs: ___
E. Provides grants and loans to develop HMOs under private sponsorship: ___
F. Required reporting and disclosure requirements for group life and health plans and allowed large employers to self-insure employee health care benefits: ___
G. Expanded Medicare and Medicaid programs, required providers to retain government insurance claims for five years: ___
H. Provision for employees to continue health care coverage beyond the benefit termination date by paying appropriate premiums: ___
I. Permitted subscribers to seek health care from providers outside a PPO by easing restrictions on preferred provider organizations (PPOs): ___
B. Provides federal government civilian employees with medical care, survivors' benefits, and compensation for lost wages: ___
C. Provides federal grants to modernize hospitals that became obsolete during the Great Depression and World War II due to a lack of funds: ___
D. Provides federal employees, retirees, and their survivors with health plans that meet their needs: ___
E. Provides grants and loans to develop HMOs under private sponsorship: ___
F. Required reporting and disclosure requirements for group life and health plans and allowed large employers to self-insure employee health care benefits: ___
G. Expanded Medicare and Medicaid programs, required providers to retain government insurance claims for five years: ___
H. Provision for employees to continue health care coverage beyond the benefit termination date by paying appropriate premiums: ___
I. Permitted subscribers to seek health care from providers outside a PPO by easing restrictions on preferred provider organizations (PPOs): ___
a. Federal Employers' Liability Act (FELA)
b. Federal Employees' Compensation Act (FECA)
c. Hill-Burton Act
d. Federal Employee Health Benefit Plan (FEHBP)
e. Health Maintenance Organization (HMO) Act of 1973
f. Employee Retirement Income Security Act of 1974 (ERISA)
g. Omnibus Budget Reconciliation Act of 1981 (OBRA)
h. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
i. Preferred Provider Health Care Act of 1985
b. Federal Employees' Compensation Act (FECA)
c. Hill-Burton Act
d. Federal Employee Health Benefit Plan (FEHBP)
e. Health Maintenance Organization (HMO) Act of 1973
f. Employee Retirement Income Security Act of 1974 (ERISA)
g. Omnibus Budget Reconciliation Act of 1981 (OBRA)
h. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
i. Preferred Provider Health Care Act of 1985
The type of plan that allows patients to seek health care from any provider, and the health plan reimburses the provider according to a fee schedule is a(n)
a. stop-loss insurance.
b. indemnity plan.
c. carve-out plan.
d. prepaid health plan.
a. stop-loss insurance.
b. indemnity plan.
c. carve-out plan.
d. prepaid health plan.
b. indemnity plan
A provision in a health or managed care plan that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each encounter or medical service received is a
a. deductible.
b. coinsurance.
c. rider.
d. copayment.
a. deductible.
b. coinsurance.
c. rider.
d. copayment.
d. copayment
Medicare is a type of
a. universal health insurance.
b. individual health insurance.
c. public health insurance.
d. group health insurance.
a. universal health insurance.
b. individual health insurance.
c. public health insurance.
d. group health insurance.
c. public health insurance
A health insurance company that provides coverage, such as BlueCross BlueShield, is a
a. subscriber.
b. rider.
c. third-party payer.
d. policyholder.
a. subscriber.
b. rider.
c. third-party payer.
d. policyholder.
c. third-party payer
The amount for which the patient is financially responsible before an insurance policy provides payment is called the
a. fee schedule.
b. coinsurance.
c. copayment.
d. deductible.
a. fee schedule.
b. coinsurance.
c. copayment.
d. deductible.
d. deductible