| indemnity health insurance plans are characterized by | freedom to choose your own healthcare providers |
| Single coverage is also known as | self-only coverage, individual coverage, or an individual plan |
| nonsingle coverage is also known as | dependent coverage |
| group health insurance is also known as | employer-based health insurance |
| a risk pool is | a group of individual entities (individuals, employers, or associations) whose healthcare costs are combined for evaluating financial history and estimating future costs |
| The least diverse type of risk pool is | an individual risk pool |
| This type of risk pool is the most diverse | large-employer pool |
| adverse selection is | having disproportionate numbers of sick people |
| The larger a risk pool is, the more able it is to | balance a wide variety of risks |
| 3 categories of commercial health insurance plans are | 1) individual health insurance plans 2) employer-based health insurance plans 3) state-sponsored plans for the medically uninsurable |
| benefits are also known as | covered services |
| The individual or entity that purchases an insurance policy is known as | a policyholder, insured, certificate holder, member, subscriber, or beneficiary |
| A deductible is | an annual amount of money that a subscriber must pay before the insurance plan will assume its share of liability for the remaining charges. |
| policy points that require the insured to pay for a portion of their healthcare services is known as | cost sharing provisions |
| state healthcare insurance plans are often called | high-risk pools |
| People who are medically uninsurable are people who | have a pre-existing condition or a chronic disease or both |
| Over the past decade, the percentage of individuals with employer-based coverage has _________ (increased/decreased) | decreased |
| A healthcare insurance policy is a | formal contract between the insurance company and individuals or groups for whom the company is assuming risk |
| insurance is also known as | a certificate of coverage, evidence of coverage, or summary plan description |
| covered conditions are | health conditions, illnesses, injuries (et.c) that the insurance company will reimburse for treatment attempting to maintain, control or cure said conditions |
| A document that plainly and concisely explains information about a healthcare insurer's benefits and its coverage of health services is a | summary of benefits and coverage (SBC) |
| Certificate numbers are used to | uniquely identify certificate holders |
| Definitions in healthcare insurance policies are important because they can | affect healthcare insurance coverage and payment |
| The prudent layperson standard is where | the decision about whether symptoms required urgent treatment or not is based on an ordinary layperson's reasonable judgement |
| Eligible dependents include | spouses, children and young adults until the age of 26, and dependents with disabilities |
| Under this provision of the ACA, healthcare insurers are required to accept every qualified individual who applies for coverage | The guaranteed issue |
| 2 exceptions of the guaranteed issue provision of the ACA are | plans that existed before the ACA and individual healthcare policies renewed in 2013 under the transitional policy for expiring coverage |
| Waiting periods (or benefits eligibility waiting periods) do not apply to | individual healthcare insurance plans |
| the waiting period for a group healthcare plan cannot exceed | 90 days |
| The term that Medicare uses instead of enrollment is | election |
| QLEs stands for | qualifying life events |
| qualifying life events that make an individual eligible to enroll during special enrollment periods include | marriage, divorce, birth, adoption, placement for adoption, and loss of other healthcare coverage |
| A stop-loss benefit is also known as the | maximum out-of-pocket cost, and the catastrophic expense limit |
| premiums ______ (are/are not) included in the maximum-out-of-pocket cost. | are not |
| 2 broad classifications of benefits are | 1) essential benefits (general healthcare services) and 2) special limited benefits (for specific situations) |
| Prescription drugs, pediatric care, maternity and newborn care, and preventive and wellness services are among 10 of the ________ benefits required by the ACA | essential |
| Medigap refers to | supplemental Medicare health insurance policies that "wrap around" the benefits of Medicare |
| Long-term care, disability income protection, and major medical (catastrophic) policies are _________ benefits. | special-limited |
| The "gaps" to be filled by supplemental insurance plans include | high deductibles and cost sharing amounts |
| The extent and number of cost sharing provisions have _______ (risen/fallen) over time. | risen |
| Coinsurance, copayments, and tiered benefits are all examples of | cost sharing provisions |
| In tiered benefits, tiers ________ (limit/extend) their members' freedom of choice of providers, amount of services allowed, and types of drugs and other services. | limit |
| Contracted discount rates in tiers refers to | using in-network providers |
| A formulary is | a preferred drug list in tiered benefits |
| A center of excellence is | a healthcare organization that performs high volumes of a service at a correspondingly high quality |
| A synonym for exclusion (pertaining to healthcare coverage) is | impairment rider |
| Typical exclusions in healthcare coverage are | experimental or investigational procedures, medically unnecessary procedures, and cosmetic procedures |
| A document that is added to a policy to provide details about coverage (or lack thereof) for special situations is known as a | rider |
| Language within a policy itself that gives additional information about coverage (or lack thereof) for special situations is known as a(n) | endorsement |
| riders and endorsements are similar to | limitations and exclusions |
| concerning healthcare insurance policies, procedures refer to | explanations of how policyholders obtain a healthcare benefit or qualify to receive the benefit |
| Common procedures (pertaining to health insurance) are | prior approval, coordination of benefits, and other party liability |
| Services that require prior approval include | outpatient surgeries; diagnostic, interventional, and therapeutic outpatient procedures; PT, OT, and speech therapies; behavioral health and substance use; inpatient care including surgery, home health, private nurses, and nursing homes; and organ transplants |
| COB stands for | Coordination of benefits |
| OPL stands for | Other party liability |
| COB and OPL procedures are used when | multiple insurance companies are involved |
| With OPL, the other party is ________ (partly/totally) responsible for paying the costs. | totally |
| The "birthday rule" in determining primary versus secondary insurance says that | a dependent child's primary insurer is the insurance of the parent whose birthday comes first in the calendar year |
| A claim is | a bill for healthcare services submitted by a hospital, physician's office, or other provider or healthcare facility. |
