ILLINOIS HEALTH INSURANCE COMPREHENSIVE
EXAMS ALL QUESTIONS AND ANSWERS SURE A+
✔✔Private Health Insurance Companies have the _____ restrictions to where the
insured can go for service - ✔✔fewest
✔✔Service Organizations - ✔✔the subscriber is entitled to obtain hospital/medical
services from any hospital/doctor service provider that is a member of the network;
outside network will not be covered
✔✔Blue Cross originally assured payment of - ✔✔hospital charges
✔✔Blue Shield originally assured payment of - ✔✔physician's charges
✔✔Preferred Provider Organizations (PPO's) - ✔✔provides medical services at
negotiated discounted rates and offer lower deductibles and co-insurance requirements
to apply if the insured receives service from a hospital in network
✔✔Health Maintenance Organization (HMO's) entitle individuals - ✔✔to obtain medical
services from hospital service providers that are part of the plan network
, ✔✔If HMO insured obtains servie from a hospital or physician service provider that is
not in network... - ✔✔insured is not covered unless in an emergency situation
✔✔HMO's have the ______ restrictions on where the insured can go for service -
✔✔greatest/most limitations
✔✔HMO's have the _____ premium rates - ✔✔lowest
✔✔HMO's practice manage healthcare to the ______extent - ✔✔greatest
✔✔Managed Health Care (MHC) requires participants to - ✔✔see a primary care
physician referred to as a "gatekeeper"
✔✔Capitated fee basis (define and purpose) - ✔✔pays the service provider a flat fee for
each participant instead of a fee-for-service
purpose to provide financial incentive to avoid unnecessary treatment and to contain
costs
✔✔Point of Service (POS) plans are issued by - ✔✔HMOs
✔✔the managed health care practiced by the HMO the insured receives - ✔✔lower
premium rates compared to private insurance risk indemnity plans, Blue Cross/Blue
Shield service plans and PPO plans
✔✔POS benefit for network - ✔✔The insured has the benefit of being able to go to
hospital/medical service providers outside of the HMO network with higher deductables
and coinsurance requirements applying
✔✔Workers Compensation Insurance - ✔✔is a type of casualty insurance not health
insurance; Private, Blue Cross/Blue Shield, PPOs and HMO plans usually exclude
expenses covered by Workers Comp
✔✔Subrogation - ✔✔is when after an insurance org pays a claim
✔✔Affordable care act ___contain impairment riders - ✔✔cannot
✔✔Impairment Rider excludes - ✔✔particular health conditions, or group of health
conditions by name
✔✔The purpose of hospital/medical expense insurance is - ✔✔to protect insureds
against the financial risk of illness or injury expenses they cannot individually afford
✔✔Essential Health Benefits (10 items) - ✔✔1. outpatient care
2. emergency room treatment
EXAMS ALL QUESTIONS AND ANSWERS SURE A+
✔✔Private Health Insurance Companies have the _____ restrictions to where the
insured can go for service - ✔✔fewest
✔✔Service Organizations - ✔✔the subscriber is entitled to obtain hospital/medical
services from any hospital/doctor service provider that is a member of the network;
outside network will not be covered
✔✔Blue Cross originally assured payment of - ✔✔hospital charges
✔✔Blue Shield originally assured payment of - ✔✔physician's charges
✔✔Preferred Provider Organizations (PPO's) - ✔✔provides medical services at
negotiated discounted rates and offer lower deductibles and co-insurance requirements
to apply if the insured receives service from a hospital in network
✔✔Health Maintenance Organization (HMO's) entitle individuals - ✔✔to obtain medical
services from hospital service providers that are part of the plan network
, ✔✔If HMO insured obtains servie from a hospital or physician service provider that is
not in network... - ✔✔insured is not covered unless in an emergency situation
✔✔HMO's have the ______ restrictions on where the insured can go for service -
✔✔greatest/most limitations
✔✔HMO's have the _____ premium rates - ✔✔lowest
✔✔HMO's practice manage healthcare to the ______extent - ✔✔greatest
✔✔Managed Health Care (MHC) requires participants to - ✔✔see a primary care
physician referred to as a "gatekeeper"
✔✔Capitated fee basis (define and purpose) - ✔✔pays the service provider a flat fee for
each participant instead of a fee-for-service
purpose to provide financial incentive to avoid unnecessary treatment and to contain
costs
✔✔Point of Service (POS) plans are issued by - ✔✔HMOs
✔✔the managed health care practiced by the HMO the insured receives - ✔✔lower
premium rates compared to private insurance risk indemnity plans, Blue Cross/Blue
Shield service plans and PPO plans
✔✔POS benefit for network - ✔✔The insured has the benefit of being able to go to
hospital/medical service providers outside of the HMO network with higher deductables
and coinsurance requirements applying
✔✔Workers Compensation Insurance - ✔✔is a type of casualty insurance not health
insurance; Private, Blue Cross/Blue Shield, PPOs and HMO plans usually exclude
expenses covered by Workers Comp
✔✔Subrogation - ✔✔is when after an insurance org pays a claim
✔✔Affordable care act ___contain impairment riders - ✔✔cannot
✔✔Impairment Rider excludes - ✔✔particular health conditions, or group of health
conditions by name
✔✔The purpose of hospital/medical expense insurance is - ✔✔to protect insureds
against the financial risk of illness or injury expenses they cannot individually afford
✔✔Essential Health Benefits (10 items) - ✔✔1. outpatient care
2. emergency room treatment
