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Questions and Answers
What is a rider in an insurance policy?
What is a rider in an insurance policy?
- A type of insurance coverage for high-risk individuals
- A provision that excludes certain conditions from a policy
- An additional feature that alters the terms of the insurance policy (correct)
- A mandatory fee for policy management
Who acts as the gate keeper in a healthcare plan?
Who acts as the gate keeper in a healthcare plan?
- Specialist physician assigned to manage complex cases
- Insurance agent responsible for policy sales
- Primary Care Provider (PCP) overseeing patient referrals (correct)
- Nurse practitioner providing direct medical services
Which of the following best describes the role of a rider?
Which of the following best describes the role of a rider?
- It limits the coverage by specifying exclusions
- It reduces the premium cost by offering less coverage
- It provides additional benefits that can modify coverage (correct)
- It is an automatic inclusion in all insurance policies
What is NOT a characteristic of a Gate Keeper?
What is NOT a characteristic of a Gate Keeper?
Which statement about riders in insurance policies is true?
Which statement about riders in insurance policies is true?
What is the function of an Explanation of Benefits (EOB)?
What is the function of an Explanation of Benefits (EOB)?
Which of the following insurance plans requires members to use providers within the network?
Which of the following insurance plans requires members to use providers within the network?
What does the deductible amount refer to in health insurance?
What does the deductible amount refer to in health insurance?
What is the purpose of the remittance advice statement (RA)?
What is the purpose of the remittance advice statement (RA)?
Which type of insurance plan allows subscribers the most flexibility in choosing healthcare providers?
Which type of insurance plan allows subscribers the most flexibility in choosing healthcare providers?
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Study Notes
Insurance Policy Basics
- Policy: The insurance product offered by a company.
- Benefits: Perks, life insurance benefits include financial payouts, medical coverage benefits include payment towards healthcare.
- Claims: When you need the insurance to cover a cost, a request is made for the insurer to pay.
- Premiums: The monthly payment made to the insurance company.
- Deductible: The amount of money you pay before your insurer starts paying for covered expenses.
- Allowable Amount: The standard fee set for each healthcare service by insurers.
Types of Healthcare Plans
- PPO (Preferred Provider Organization): A managed care plan that encourages but does not require using providers within the network.
- Indemnity Plan: A plan that allows you to choose any provider or healthcare facility.
- HMO (Health Maintenance Organizations): A managed care plan that requires members to use providers within the HMO system.
Managed Care
- Providers agree to provide discounted prices and dismiss any additional costs.
- Co-insurance: A type of insurance where both the insured and insurer share the cost of covered expenses.
Coverage and Costs
- Out-of-Pocket Maximum: The highest amount an insured person will need to pay for healthcare costs during a coverage period.
- Person Days: The amount of days covered by a health insurance plan for covered healthcare services per year. After reaching the maximum, the insurance pays the remaining cost.
- Dependents: Family members or individuals under the care of the policy holder.
Additional Information
- Guarantor: The person financially responsible for paying medical bills.
- EOB (Explanation of Benefits): A summary of coverage received by policyholders.
- RA (Remittance Advice Statement): A provider form outlining dates of service, charges, and the amount the patient pays.
- Medicare: A federal government program providing healthcare services to adults, children, pregnant women, elderly, low-income adults, and individuals with disabilities.
- Tricare: Insurance for US Military members, former members, and their families.
Policy Additions and Practices
- Riders: Additions to an insurance policy that modify the policy's terms.
- Gatekeeper: Your primary care provider (PCP), who acts as a gatekeeper to specialists in the managed care system.
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