Hawaii Health Insurance Exam: Chapter 1 Questions and Answers with complete

3 Types of Medical Expense Insurance: - Answer-Basic Hospital, Medical and Surgical (may be purchased together or separately and are sometimes called "first dollar" because they do not have deductibles) Relative Value - Answer-The relative value approach - each procedure is assigned a number of "points" relative to the number of appoints assigned to the maximum benefit (where as the total amount payable per point is the Conversion Factor) Basic Medical Expense Coverage - Answer-Offers wide range of limited benefits often resulting in high out-of-pocket expenses. Can cover maternity, mental and nervous disorder, hospice care and more (non-surgical) expenses Major Medical Policies - Answer-Carry a deductible, but pickup where basic medical expense coverage leaves off Supplementary Major Medical Policies - Answer-Used to support the coverage payable under a basic medical expense policy The corridor deductible - Answer-The corridor refers to the gap between where the basic coverage leaves off and the major picks up (amount paid by insured) The Relative Value Approach - Answer-Used in some Basic Surgical Expense Coverage policies, assigns points to all operations covered and uses a conversion factor to determine the total amount payable per point Comprehensive Major Medical Policies - Answer-A combo of basic and major medical coverage generally including low premiums, high maximums and coinsurance HMOs (Health Maintenance Organizations) - Answer-The main goal of HMOs is to offer preventative health care. HMOs are unique in that they provide BOTH the patient care and the financing for its members. HMOs are Primary Care Physician (gatekeeper) based and require referrals from a member's PCP in order to see a specialist.Copayments - Answer-Copayments are a flat dollar amount that must be paid by the member (e.g. $5, $10 or $25 for each Dr.s office visit) PPOs (Preferred Provider Organizations) - Answer-PPOs offer members the ability to select Dr.s and specialists on their own and those medical professionals are paid on a fee-based basis (not prepaid/salaried like an HMO). Additionally, members may see medical professionals who do NOT belong to the PPO's group, but the percentage of cost covered may be lower (i.e. 90% for in-group vs. 70% out-of-network) POS Plans (Point-of-Service plans) - Answer-POS plans are a combination of HMOs & PPOs meaning the participant may have access to a network controlled by their PCP (gatekeeper) but they may also opt for care outside network at reduced coverage levels. POS plans are also referred to as "openended HMOs" HDHPs (high deductible health plans) - Answer-Higher annual deductibles and out-of-pocket limits, which means lower premiums. Preventative care services are generally still First Dollar. HSAs (Health Savings Accounts) - Answer-Designed for individuals saving for qualified health expenses for themselves or a dependent. Someone covered by a HDHP can make tax-deductible contributions to an HSA and use it to pay out-of-pocket medical expenses (individuals covered by an HSA MUST NOT BE ELIGIBLE FOR MEDICARE)