38 Questions
What is the main similarity between dental fee-for-service plans and medical fee-for-service plans?
Both cover routine and necessary procedures
In what way are dental maintenance organizations (dental HMOs) most similar to HMOs?
Both focus on cost-effective preventive care
What do prescription card programs offer?
Prepaid benefits with nominal copayments
Which federal law requires employers to treat pregnancy as other disabilities?
Pregnancy Discrimination Act of 1978
What do dental service corporations represent?
Nonprofits owned by state dental associations
In a fee-for-service plan, who receives the cash benefit?
The employee
What is a key characteristic of managed care plans?
Emphasis on cost control
Which type of managed care plan may cover emergency care outside the network?
Health Maintenance Organizations (HMOs)
What is a characteristic of a staff model HMO?
It owns the medical facilities
What do prepaid group practices cover in an open-access HMO?
Only services with a provider in the network
What is the main reason for the 450% increase in healthcare costs since 1984?
Medical advances
What type of benefits cover hospital expenses not requiring overnight stays?
Outpatient benefits
Which federal regulation oversees the enforcement of the American with Disabilities Act (ADA)?
IRS
What is the main action of the Employee Retirement Income Security Act of 1974 (ERISA)?
Amendments including COBRA, HIPAA, and Women’s Health and Cancer Rights Act of 1998
What is the consequence for companies known to 'pay or play' but fail to offer affordable coverage?
Loss of tax exemption
In a point-of-service (POS) plan, what is a requirement that distinguishes it from a PPO?
Requiring a primary care physician
How is an exclusive provider organization (EPO) different from a PPO?
Paying on a reimbursement basis and not requiring a primary care physician
What do health-care plans commonly require employees to do before paying for benefits?
Meet a deductible
What is a feature commonly shared by point-of-service (POS) plans and HMOs?
Requiring a primary care physician
What is the main distinguishing factor of preferred provider organizations (PPOs)?
Reimbursing providers at a lower level
What distinguishes a prepaid plan from an indemnity plan?
Prepaid plans pay healthcare providers a fixed amount based on the number of individuals covered, while indemnity plans reimburse recognized health care providers.
What is a key difference in the tax regulations for insurance plans and self-funded plans?
Companies can take deductions for providing health plans or paying claims directly in self-funded plans, but not in insurance plans.
Which organization addresses issues related to state regulations for health-care plans?
National Association of Insurance Commissioners (NAIC)
Under state regulations, what is one of the four areas of responsibility that every state law addresses for fully insured plans?
Who must be covered
What do tax regulations allow companies to take deductions for in relation to health plan premiums?
Companies can take deductions for their contribution to health plan premiums as long as there is no preferential treatment to highly compensated employees.
What does coinsurance refer to in health-care plans?
The percentage paid by the insured after meeting the deductible
What is meant by 'out-of-pocket maximum' in health-care plans?
The maximum amount the insured must pay per calendar year
What is the purpose of preadmission certification of medical necessity for hospitalization in health-care plans?
To reduce unnecessary surgical procedures and costs
What is the main characteristic of a high-deductible health insurance plan (HDHP) in consumer-driven health care?
Higher deductibles
What is the purpose of carve-out plans in employer-provided health-care benefits?
A contract agreement to provide special services
What is the main distinction between fully insured and self-funded health-care plans?
The responsibility for offering benefits and paying claims
In the context of health-care plans, what does 'single coverage' refer to?
Covered employees and qualified dependents receive benefits
In the U.S. healthcare system, what does a multiple-payer system mean?
More than one party is responsible for coverage
What is the main difference between fee-for-service plans and consumer-driven health care?
High deductibles and medical cost sharing
What do mortality tables indicate in the context of fully insured health-care plans?
Yearly probabilities of death based on age and sex
What is the primary factor that makes self-funding sensible for employers in providing health-care coverage?
Covering employee medical expenses being less than insurance coverage
What do morbidity tables express in the context of health-care plans?
Annual probabilities of the occurrence of health problems
In fully insured plans, what do experience ratings specify?
The incident, type, and financial cost of insurance claims for groups
This quiz assesses knowledge of tax regulations related to providing health plans and paying claims directly as per the IRC. It covers deductions for insurance plans and self-funded plans, and the rules regarding preferential treatment to highly compensated employees.
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