Chapter 03

Question 1

Earned Premium

Answer 1

Portion of a premium for which protection has already been given

Question 2

Unearned Premium

Answer 2

Portion of a premium for which policy protection has not yet been given

Question 3

Service Area

Answer 3

The primary geographical area of coverage and service provided by a Health
Maintenance Organization (HMO)

Question 4

Payment Structure: Blanket Payment

Answer 4

Maximum dollar limit set, with no itemizing of costs, used for groups covered
under a blanket policy for a specified period or event.
(sports or events)

Question 5

Payment Structure: Scheduled Payment

Answer 5

A health plan with limits as to what will be paid for covered expenses. most associated with covering day to day losses based on a specified (universal) or flat dollar amount. Scheduled benefit plans are not designed to cover catastrophic losses and have
limited annual benefits.

Question 6

Payment Structure: Cash or Indemnity Payment

Answer 6

Pays a specified daily amount up to the stated
maximum number of days, or even lifetime. Benefits often double or triple while an insured is
confined in an intensive care unit.

Question 7

Payment Structure: Fee-for-Service

Answer 7

Provides a separate payment to a healthcare provider for each medical service
received by a patient.

Question 8

Payment Structure: Prepaid

Answer 8

Medical benefits are provided to a subscriber in exchange for predetermined monthly
premiums paid in advance.

Question 9

Payment Structure: Usual, Customary, Reasonable

Answer 9

Benefits are not scheduled, but are based on the

average fee charged by all providers in a given geographical area.

Question 10

Payment Structure: Lifetime Limit

Answer 10

maximum a policy will pay for covered losses during the lifetime of an
insured.

Question 11

Payment Structure: Annual Limit

Answer 11

maximum a policy will for covered losses per year

Question 12

Payment Structure: Per-Cause

Answer 12

maximum a policy will pay for covered losses per claim.

Question 13

Blues

Answer 13

Negotiate price with doctors
prepaid plans, with plan subscribers paying a set fee, usually
monthly, for the services of doctors and hospitals at a predetermined price (negotiated fee).
Not for profit, special regulation

Question 14

HMOs

Answer 14

Subscribers; Must visit providers within a service area; Providers are paid capitalization fee per subscriber; Preventative care with primary physician; no claims, bills, or deductibles; copay for admin fees; emergency allows for outside network providers; Gatekeeper must approve specialist visit;

Question 15

HMO: Group Model

Answer 15

independent medical group to provide a variety of medical services to subscribers.

Question 16

HMO: Staff Model (Closed-Panel)

Answer 16

Contracting physicians are paid employees working on the staff of the HMO.

Question 17

HMO: Independent Practice Association (IPA) Model (Open-Panel)

Answer 17

Health Maintenance Organizations
maximum freedom of choice of physicians and locations
because the HMO is allowed to contract with a network of independent physicians who are part of an independent practice association. Physicians operate out of their own private offices and subscribers may be individuals the physicians were already treating.

Question 18

PPOs

Answer 18

Preferred Provider Organizations
Subscribers have more choices among doctors and hospitals under a PPO arrangement. Subscribers
can choose a preferred provider or out of network provider. If an out-of-network provider is utilized,
the PPO pays a reduced amount and the subscriber will have a larger out-of-pocket cost.

Question 19

Exclusive Provider Organization (EPO)

Answer 19

seek treatment from a network provider.

Unlike an HMO, use of a primary care physician and referral to a specialist are not required

Question 20

Point of Service (POS)

Answer 20

These Plans combine PPO and HMO benefits.

Question 21

Basic Medical Expense

Answer 21

Pays for office visits, nonsurgical doctor visits, diagnostic x-rays,
laboratory charges, ambulance, and nursing expenses when not hospitalized.

Question 22

Basic Hospital Expense

Answer 22

Pays for a hospital room and board (semi-private) with a daily limit
of coverage. Miscellaneous hospital expenses may also be provided

Question 23

Basic Surgical Expense

Answer 23

– Pays surgeon and anesthesiologist fees for the cost of a surgical
procedure

Question 24

“First Dollar” coverage.

Answer 24

From the start of the event. They pay the 1st dollar up to a specified limit. If a surgery is not listed in the policy, the company
will pay based on the coverage of a comparable surgery.

Question 25

Major Medical Expense

Answer 25

catastrophic and/or prolonged injury | or illness

Question 26

Stop-Loss Provision

Answer 26

A maximum dollar limit set on the coinsurance to limit the out-of-pocket expense that an insured can incur in a policy year.

Question 27

Common Accident Deductible

Answer 27

If several family members are injured in the same | accident, only one deductible is applied

Question 28

Carryover Provision

Answer 28

Accidents in the last three months of the year will be used to the next year's deductible if the current year's deductible was not reached

Question 29

Supplemental Major Medical Policy

Answer 29

Once the Basic Plan benefits are exhausted, a Corridor Deductible is required to be paid before the start of coverage under the Supplemental Major Medical plan.

Question 30

Comprehensive Major Medical Policy

Answer 30

This policy requires an initial Flat Deductible that is paid before the Basic plan begins to provide coverage.

Question 31

Newborn Infant Coverage

Answer 31

insured’s newborn child from the moment of birth Adopted children are covered at the date of placement for adoption. . Notification of birth or adoption and payment of the required premium must be within a month (30-31 days)

Question 32

Limited Accident

Answer 32

Such as travel, is not renewable

Question 33

Endodontics

Answer 33

Services covering dental pulp care and root canals

Question 34

Orthodontics

Answer 34

– Services for teeth alignment and other irregularities of the teeth

Question 35

Periodontics

Answer 35

Services for the treatment of gum problems and disease

Question 36

Prosthodontics

Answer 36

Services provide bridgework and dentures

Question 37

Restorative Care

Answer 37

– Services to restore the functional use of natural teeth

Question 38

Oral Surgery

Answer 38

Surgical treatment of diseases, injuries and jaw defects

Question 39

Exclusions

Answer 39

■ Purely cosmetic services (unless necessitated by an accident) ■ Replacement of prosthetic devices ■ Duplicate dentures or prosthetic devices ■ Oral hygiene instruction or training ■ Occupational injuries covered by Workers’ Compensation ■ Services furnished by or on behalf of government agencies ■ Certain services that began prior to the date of coverage