HSA 408 Final Exam Study Guide #2 Ch. 8-14
With Complete Solutions
True or False?
Insurance is rooted in the concepts of uncertainty and risks; reducing uncertainty and
risk by, for example offering an health insurance product, participating as a provider in
a health insurance plan, or purchasing health insurance coverage as a consumer
creates various incentives for insurers, the insured, providers and governments to act
or refrain from acting in certain ways. - ANSWER -True.
People choose to be insured because of what two things? - ANSWER -Uncertainty and
risk.
Define Beneficiary (insured). - ANSWER -consumer, the individual who is covered by the
plan.
-buys health insurance in advance for an annual fee.
Define Premium. - ANSWER -Annual fee paid by the beneficiary to the health plan,
usually in monthly installment plans, to secure health insurance coverage.
Define Deductible. - ANSWER -Amount of money a beneficiary must pay out-of-pocket
before the insurance company assists with paying for services.
Define Cost-sharing. - ANSWER -Copayment or co-insurance, an amount the beneficiary
pays per service after the deductible is met.
why are insurance companies concerned about uncertainty and risk? - ANSWER -they
are businesses that need to cover the cost of their expenditures.
-may lead to adverse selection.
-unhealthy people over-select a particular plan, making the plan more expensive.
,Insurance companies set premiums to cover most of their experiences, what are the two
rating types? - ANSWER -Community rating: based on factors unrelated to previous use
of medical care, such as geography/age.
-All persons in the community rating system pay the same amount.
-Experience rating: based on health status & claims in prior year(s).
-Also referred to as medical underwriting.
Describe Health Insurance Portability and Accountability Act of 1996 (HIPAA). -
ANSWER -Covered group plans may not exclude or limit otherwise qualified individuals
due to pre-existing conditions.
-covered group plans may not charge different premiums based on identified health
factors similarly situated individuals.
-State laws on medical underwriting may vary.
Describe Managed Care. - ANSWER -integrates the provision and payment of healthcare
services.
-contains costs while providing necessary and high-quality healthcare services.
-Some fear they provide fewer services than necessary or lower quality services to save
money.
Describe Managed Care Cost Containment Tools. - ANSWER -Performance-based
salary: provider receives a salary as a managed care organization employee. Salary is
subject to bonuses or withholds
-Discounted fee schedule: provider accepts less than fee-for-service rates to participate
in managed care network.
-Capitated Payment: provider receives a per member/per month payment for all
services rendered within scope of practice.
What are the Managed Care-Utilization Control Tools. - ANSWER -Gatekeeper
-Utilization Review.
, -Case Management.
Describe Gatekeeper. - ANSWER -Managed care organization uses a primary care
provider to make sure only necessary and appropriate care is provided.
Describe Utilization review. - ANSWER -Managed care organization review and
approves or denies services requested by provider.
Describe Case Management. - ANSWER -Managed care organization manages and
coordinates patient care.
What are the Managed Care- Common Structures. - ANSWER -Health Maintenance
Organization (HMO).
-Preferred Provider Organization (PPO).
-Point of Service Plans (POS).
Describe Health Maintenance Organization. (HMO). - ANSWER -Pays providers a salary
or capitation.
-Beneficiaries may only use in-network providers.
-Coordinates and controls receipt of services.
Describe Preferred Provider Organization (PPO). - ANSWER -Pays provider on a
discounted fee schedule.
-Beneficiary may use in-or out-of-network providers.
Describe Point of Service Plans (POS). - ANSWER -Combines features of HMO & PPO.
-Pays providers with capitation or other risk-sharing arrangement.
-Has a provider network; beneficiaries may use out-of-network provider for designated
services.
-Has a gatekeeper to control and coordinate care.
With Complete Solutions
True or False?
Insurance is rooted in the concepts of uncertainty and risks; reducing uncertainty and
risk by, for example offering an health insurance product, participating as a provider in
a health insurance plan, or purchasing health insurance coverage as a consumer
creates various incentives for insurers, the insured, providers and governments to act
or refrain from acting in certain ways. - ANSWER -True.
People choose to be insured because of what two things? - ANSWER -Uncertainty and
risk.
Define Beneficiary (insured). - ANSWER -consumer, the individual who is covered by the
plan.
-buys health insurance in advance for an annual fee.
Define Premium. - ANSWER -Annual fee paid by the beneficiary to the health plan,
usually in monthly installment plans, to secure health insurance coverage.
Define Deductible. - ANSWER -Amount of money a beneficiary must pay out-of-pocket
before the insurance company assists with paying for services.
Define Cost-sharing. - ANSWER -Copayment or co-insurance, an amount the beneficiary
pays per service after the deductible is met.
why are insurance companies concerned about uncertainty and risk? - ANSWER -they
are businesses that need to cover the cost of their expenditures.
-may lead to adverse selection.
-unhealthy people over-select a particular plan, making the plan more expensive.
,Insurance companies set premiums to cover most of their experiences, what are the two
rating types? - ANSWER -Community rating: based on factors unrelated to previous use
of medical care, such as geography/age.
-All persons in the community rating system pay the same amount.
-Experience rating: based on health status & claims in prior year(s).
-Also referred to as medical underwriting.
Describe Health Insurance Portability and Accountability Act of 1996 (HIPAA). -
ANSWER -Covered group plans may not exclude or limit otherwise qualified individuals
due to pre-existing conditions.
-covered group plans may not charge different premiums based on identified health
factors similarly situated individuals.
-State laws on medical underwriting may vary.
Describe Managed Care. - ANSWER -integrates the provision and payment of healthcare
services.
-contains costs while providing necessary and high-quality healthcare services.
-Some fear they provide fewer services than necessary or lower quality services to save
money.
Describe Managed Care Cost Containment Tools. - ANSWER -Performance-based
salary: provider receives a salary as a managed care organization employee. Salary is
subject to bonuses or withholds
-Discounted fee schedule: provider accepts less than fee-for-service rates to participate
in managed care network.
-Capitated Payment: provider receives a per member/per month payment for all
services rendered within scope of practice.
What are the Managed Care-Utilization Control Tools. - ANSWER -Gatekeeper
-Utilization Review.
, -Case Management.
Describe Gatekeeper. - ANSWER -Managed care organization uses a primary care
provider to make sure only necessary and appropriate care is provided.
Describe Utilization review. - ANSWER -Managed care organization review and
approves or denies services requested by provider.
Describe Case Management. - ANSWER -Managed care organization manages and
coordinates patient care.
What are the Managed Care- Common Structures. - ANSWER -Health Maintenance
Organization (HMO).
-Preferred Provider Organization (PPO).
-Point of Service Plans (POS).
Describe Health Maintenance Organization. (HMO). - ANSWER -Pays providers a salary
or capitation.
-Beneficiaries may only use in-network providers.
-Coordinates and controls receipt of services.
Describe Preferred Provider Organization (PPO). - ANSWER -Pays provider on a
discounted fee schedule.
-Beneficiary may use in-or out-of-network providers.
Describe Point of Service Plans (POS). - ANSWER -Combines features of HMO & PPO.
-Pays providers with capitation or other risk-sharing arrangement.
-Has a provider network; beneficiaries may use out-of-network provider for designated
services.
-Has a gatekeeper to control and coordinate care.
