ARIZONA HEALTH INSURANCE STANDARD EXAMS
ANSWERS AND QUESTIONS SET A+
✔✔The __________ the stop-loss, the lower the premium. - ✔✔higher
✔✔What is a maximum benefit? - ✔✔The maximum amount that an insurance company
will pay over a lifetime.
✔✔What is the main goal of Health Maintenance Organizations (HMOs)? - ✔✔to reduce
the cost of health care by utilizing preventive care; offer a free annual check up for the
entire family; hope to catch diseases in their earliest stages when treatment has the
greatest chance for success; free or low-cost immunizations
✔✔HMOs provide benefits in the form of __________ rather than in the form of
reimbursement for the services of the physician or hospital. - ✔✔services
✔✔Characteristics of HMOs - ✔✔- preventive care services
- limited services areas
- limited choices of providers
- copayments
- prepaid plans
- selection of a PCP
- referrals from PCP to a specialist
- inpatient hospital or emergency care in or out of the service area
✔✔Capitated Basis - ✔✔the HMO receives a flat amount each month attributed to each
member, whether they see a physician or not
✔✔HMOs have the option of providing one or more of the following supplemental
benefits: - ✔✔- long term heath care
-nursing services
- home health care
- prescription drugs
,- dental care
-vision care
- mental health care
- substance abuse services
✔✔With a Preferred Provider Organization (PPO), while the members can utilize any
physician they choose, the PPO may provide __________ of the cost of a physician on
their approved list while possibly only providing for __________ of the cost if the
member chooses to utilize a physician not included in the PPO's approved list. -
✔✔90%/70%
✔✔In what two ways do PPOs differ from HMOs? - ✔✔1. they do not provide care on a
prepaid basis, but physicians are paid a fee for service
2. subscribers are not required to use physicians or facilities that have contracts with the
PPO
✔✔Open Panel - ✔✔when a medical caregiver contracts with a health organization to
provide services to its members or subscribers, but retains the right to treat patients
who are not members or subscribers; doctors are not considered to be employees of
the health organization
✔✔Closed Panel - ✔✔when the medical caregiver provides services to only members
or subscribers of a health organization, and contractually is not allowed to treat other
patients; doctors are considered employees of the health organization
✔✔When and who can be added to a PPO provider list? - ✔✔Providers and hospitals
can be added at any time and they may belong to several PPO groups at once.
✔✔What is a Point of Service plan? - ✔✔a combination of a PPO and an HMO;
members do not have to be locked in to one plan or make a choice between two plans,
they can make a difference choice every time a need arises for medical services
✔✔In a __________ plan, members can visit an in-network provider at their discretion.
If they decide to use an out-of-network physician, they may do so. However, the
member copays, coninsurance and deductibles may be substantially higher. - ✔✔Point
of Service
✔✔In a PPO, the insured __________ to select a primary care physician. - ✔✔does not
have
✔✔If a non-member physician is utilized under the __________, then the attending
physician will be paid a fee for service, but the member patient will have to pay a higher
coinsurance amount or percentage for the privilege. - ✔✔Point of Service Plan
,✔✔__________ are corporations organized under the laws of this state to establish,
maintian and operate nonprofit service plans for hospital, medical, dental and
optometric services. These corporations contract with medical professionals to provide
medical care to subscribers. - ✔✔Hospital service corporations, medical service
corporations, dental service corporations and optometric service corporations
✔✔__________ means any entity that conducts one or more health care plans and
includes provider sponsored health care services organizations. - ✔✔Health Care
Services Organization (HCSO)
✔✔The Health Care Services Organization (HCSO) must have an organized system for
the delivery of health care services that includes the following: - ✔✔- contracted
providers of services under the plan
- a process for promoting a continuing relationship between an enrollee and the same
primary care physician
- a process for referrals that ensures continuity of care to an enrollee
✔✔Within a geographic area, the HCSO's health care plan must provide the following
basic health care services covered by the monthly charges in the evidence of coverage:
- ✔✔- emergency care that includes emergency services and inpatient emergency care
- inpatient care
- specialty care, primary care, or ancillary care that includes diagnostic and therapeutic
services
- outpatient care
- preventive care
- emergency ambulatory services and other ambulance services when approved by a
plan physician
✔✔Maximum Out of Pocket Limits - ✔✔the most the policy owner will have to pay for
covered services in a plan year
✔✔What is the current maximum out of pocket limit for any marketplace plan? -
✔✔$6,850 for an individual plan, $13,700 for a family plan
✔✔With the dramatic rise in the cost of medical care over the past few decades, the
concept of __________ has become a necessity for insurance companies. -
✔✔managed care
✔✔__________ plans, such as HMOs and PPOs, are designed to control costs by
controlling the behavior of the plan participants. - ✔✔Managed care
✔✔__________ is a system for reviewing the appropriateness and efficient allocation of
health care services and resources that are being given or are proposed to be given to
an insured. - ✔✔Utilization management
, ✔✔Under the __________ or __________ of utilization management, the physician can
submit clain information prior to providing treatment to know in advance if the procedure
is covered under the insured's plan and at what rate it will be paid. - ✔✔prospective
review/precertification process
✔✔Under the ___________ of utilization management, the insurance company will
monitor the insured's hospital stay to make sure that everything is proceeding according
to schedule and that the insured will be released from the hospital as planned. -
✔✔concurrent review process
✔✔What are the strategies used by managed care plans? - ✔✔- providing financial
incentives for members to use providers and procedures approved by the plan
- controlling lengths of hospital stay
- using utilization reviews to improve case management
- focus on preventive health care
✔✔What does newborn child coverage entail? - ✔✔- coverage for the newborn child of
the insured from the moment of birth
- coverage for injury or sickness
- coverage for necessary care and treatment of medically diagnosed congenital birth
defects and birth abnormalities
✔✔Notification of the birth of a newborn child and payment of the required premium
must be furnished to the insurance company within ___________ after the date of birth
in order to have coverage continue beyond that period. - ✔✔31 days
✔✔If adoption does not occur at birth, when will coverage of the adopted child be
effective? - ✔✔From the date of placement for adoption if a petition for adoption is filed
within 31 days of the placement
✔✔Maternity benefits only apply to adopted children in the following circumstances: -
✔✔- the child was adopted within 1 year of birth
- the insured is legally obligated to pay the costs of birth
- all pre-existing conditions and other limitations have been met by the insured
- the insured has notified the insurer of the insured's acceptability to adopt children,
within 60 days of that approval or of a change in insurance companies or policies
✔✔After the birth of a child, a hospital stay will be covered for __________ for normal
delivery and __________ for cesarean section. - ✔✔48 hours/96 hours
✔✔Insurers and health care providers may not deny enrollment of a child under a health
insurance plan or evidence of coverage of a child's parent for any of the following
reasons: - ✔✔- the child was born out of wedlock
ANSWERS AND QUESTIONS SET A+
✔✔The __________ the stop-loss, the lower the premium. - ✔✔higher
✔✔What is a maximum benefit? - ✔✔The maximum amount that an insurance company
will pay over a lifetime.
✔✔What is the main goal of Health Maintenance Organizations (HMOs)? - ✔✔to reduce
the cost of health care by utilizing preventive care; offer a free annual check up for the
entire family; hope to catch diseases in their earliest stages when treatment has the
greatest chance for success; free or low-cost immunizations
✔✔HMOs provide benefits in the form of __________ rather than in the form of
reimbursement for the services of the physician or hospital. - ✔✔services
✔✔Characteristics of HMOs - ✔✔- preventive care services
- limited services areas
- limited choices of providers
- copayments
- prepaid plans
- selection of a PCP
- referrals from PCP to a specialist
- inpatient hospital or emergency care in or out of the service area
✔✔Capitated Basis - ✔✔the HMO receives a flat amount each month attributed to each
member, whether they see a physician or not
✔✔HMOs have the option of providing one or more of the following supplemental
benefits: - ✔✔- long term heath care
-nursing services
- home health care
- prescription drugs
,- dental care
-vision care
- mental health care
- substance abuse services
✔✔With a Preferred Provider Organization (PPO), while the members can utilize any
physician they choose, the PPO may provide __________ of the cost of a physician on
their approved list while possibly only providing for __________ of the cost if the
member chooses to utilize a physician not included in the PPO's approved list. -
✔✔90%/70%
✔✔In what two ways do PPOs differ from HMOs? - ✔✔1. they do not provide care on a
prepaid basis, but physicians are paid a fee for service
2. subscribers are not required to use physicians or facilities that have contracts with the
PPO
✔✔Open Panel - ✔✔when a medical caregiver contracts with a health organization to
provide services to its members or subscribers, but retains the right to treat patients
who are not members or subscribers; doctors are not considered to be employees of
the health organization
✔✔Closed Panel - ✔✔when the medical caregiver provides services to only members
or subscribers of a health organization, and contractually is not allowed to treat other
patients; doctors are considered employees of the health organization
✔✔When and who can be added to a PPO provider list? - ✔✔Providers and hospitals
can be added at any time and they may belong to several PPO groups at once.
✔✔What is a Point of Service plan? - ✔✔a combination of a PPO and an HMO;
members do not have to be locked in to one plan or make a choice between two plans,
they can make a difference choice every time a need arises for medical services
✔✔In a __________ plan, members can visit an in-network provider at their discretion.
If they decide to use an out-of-network physician, they may do so. However, the
member copays, coninsurance and deductibles may be substantially higher. - ✔✔Point
of Service
✔✔In a PPO, the insured __________ to select a primary care physician. - ✔✔does not
have
✔✔If a non-member physician is utilized under the __________, then the attending
physician will be paid a fee for service, but the member patient will have to pay a higher
coinsurance amount or percentage for the privilege. - ✔✔Point of Service Plan
,✔✔__________ are corporations organized under the laws of this state to establish,
maintian and operate nonprofit service plans for hospital, medical, dental and
optometric services. These corporations contract with medical professionals to provide
medical care to subscribers. - ✔✔Hospital service corporations, medical service
corporations, dental service corporations and optometric service corporations
✔✔__________ means any entity that conducts one or more health care plans and
includes provider sponsored health care services organizations. - ✔✔Health Care
Services Organization (HCSO)
✔✔The Health Care Services Organization (HCSO) must have an organized system for
the delivery of health care services that includes the following: - ✔✔- contracted
providers of services under the plan
- a process for promoting a continuing relationship between an enrollee and the same
primary care physician
- a process for referrals that ensures continuity of care to an enrollee
✔✔Within a geographic area, the HCSO's health care plan must provide the following
basic health care services covered by the monthly charges in the evidence of coverage:
- ✔✔- emergency care that includes emergency services and inpatient emergency care
- inpatient care
- specialty care, primary care, or ancillary care that includes diagnostic and therapeutic
services
- outpatient care
- preventive care
- emergency ambulatory services and other ambulance services when approved by a
plan physician
✔✔Maximum Out of Pocket Limits - ✔✔the most the policy owner will have to pay for
covered services in a plan year
✔✔What is the current maximum out of pocket limit for any marketplace plan? -
✔✔$6,850 for an individual plan, $13,700 for a family plan
✔✔With the dramatic rise in the cost of medical care over the past few decades, the
concept of __________ has become a necessity for insurance companies. -
✔✔managed care
✔✔__________ plans, such as HMOs and PPOs, are designed to control costs by
controlling the behavior of the plan participants. - ✔✔Managed care
✔✔__________ is a system for reviewing the appropriateness and efficient allocation of
health care services and resources that are being given or are proposed to be given to
an insured. - ✔✔Utilization management
, ✔✔Under the __________ or __________ of utilization management, the physician can
submit clain information prior to providing treatment to know in advance if the procedure
is covered under the insured's plan and at what rate it will be paid. - ✔✔prospective
review/precertification process
✔✔Under the ___________ of utilization management, the insurance company will
monitor the insured's hospital stay to make sure that everything is proceeding according
to schedule and that the insured will be released from the hospital as planned. -
✔✔concurrent review process
✔✔What are the strategies used by managed care plans? - ✔✔- providing financial
incentives for members to use providers and procedures approved by the plan
- controlling lengths of hospital stay
- using utilization reviews to improve case management
- focus on preventive health care
✔✔What does newborn child coverage entail? - ✔✔- coverage for the newborn child of
the insured from the moment of birth
- coverage for injury or sickness
- coverage for necessary care and treatment of medically diagnosed congenital birth
defects and birth abnormalities
✔✔Notification of the birth of a newborn child and payment of the required premium
must be furnished to the insurance company within ___________ after the date of birth
in order to have coverage continue beyond that period. - ✔✔31 days
✔✔If adoption does not occur at birth, when will coverage of the adopted child be
effective? - ✔✔From the date of placement for adoption if a petition for adoption is filed
within 31 days of the placement
✔✔Maternity benefits only apply to adopted children in the following circumstances: -
✔✔- the child was adopted within 1 year of birth
- the insured is legally obligated to pay the costs of birth
- all pre-existing conditions and other limitations have been met by the insured
- the insured has notified the insurer of the insured's acceptability to adopt children,
within 60 days of that approval or of a change in insurance companies or policies
✔✔After the birth of a child, a hospital stay will be covered for __________ for normal
delivery and __________ for cesarean section. - ✔✔48 hours/96 hours
✔✔Insurers and health care providers may not deny enrollment of a child under a health
insurance plan or evidence of coverage of a child's parent for any of the following
reasons: - ✔✔- the child was born out of wedlock
