PHS Health Insurance Study Guide
Exam and Actual Answers.
health insurance - Answer plan that helps the consumer pay for medical costs, no plan pays
100%
Why do we need it? - Answer just in case
pre-existing condition - Answer an illness already present when applying for a new insurance
plan
guaranteed issue - Answer law that states all individuals in a given population must be
insured
DRGs(Diagnosis Related Groups) - Answer Medicare pays a set amount for specific
classifications of diagnosis
tort reform - Answer laws limiting medical malpractice suit payments
COBRA(Consolidated Omnibus Budget Reconciliation Act 1986) - Answer employee can pay
to keep group health insurance for 18-36 months after leaving a job/losing health insurance,
prevents "lapse in coverage" situation which prevents issues with pre-existing condition
premium - Answer amount you pay to belong to a health plan
deductible - Answer amount you must pay each year before health plan begins paying
co-insurance - Answer percent of medical costs a person must pay after meeting deductible
co-pay - Answer set fee paid each time person receives medical care
Where can you get insurance? - Answer -group insurance: employee offers plan to workers,
share cost of premiums
-individual insurance: purchase plan directly from insurance company, pay own premiums
options available - Answer -can choose provider
-deductible and co-insurance
, -patient must file an insurance claim for each service themselves and pay the doctor's office for
treatment at time of services
managed care plans: - Answer -"network" of providers on the plan
-costs lower of use network providers
-no insurance claim forms
-co-pays
HMO(Health Maintenance Organization) - Answer -receive most of care from primary care
doctor
-specialists require a referral
-will only pay for network providers
-pays for routine and preventative care
PPO(Preferred Provider Organization) - Answer -no referrals for specialists
-can use network/non-network providers
-pay more for non-network
Medicare - Answer -fed gov health plan
-health coverage for age 65+ and certain disabilities
-plan A: hospital coverage, no premium
-plan B: physician coverage, premium, optional
-treat patients w/ ADLs
Medicaid - Answer -fed gov health plan
-administered by states
-covers those w/ low income and disabled
- eligibility and benefits vary by state
SCHIP/CHIP(State Children's Health Insurance Program) - Answer -state medical coverage for
low income children who don't qualify for Medicaid
worker's compensation - Answer -covers medical care for on-the-job injuries
-covers part of wages lost due to injury
-cost shared by state and employee
Exam and Actual Answers.
health insurance - Answer plan that helps the consumer pay for medical costs, no plan pays
100%
Why do we need it? - Answer just in case
pre-existing condition - Answer an illness already present when applying for a new insurance
plan
guaranteed issue - Answer law that states all individuals in a given population must be
insured
DRGs(Diagnosis Related Groups) - Answer Medicare pays a set amount for specific
classifications of diagnosis
tort reform - Answer laws limiting medical malpractice suit payments
COBRA(Consolidated Omnibus Budget Reconciliation Act 1986) - Answer employee can pay
to keep group health insurance for 18-36 months after leaving a job/losing health insurance,
prevents "lapse in coverage" situation which prevents issues with pre-existing condition
premium - Answer amount you pay to belong to a health plan
deductible - Answer amount you must pay each year before health plan begins paying
co-insurance - Answer percent of medical costs a person must pay after meeting deductible
co-pay - Answer set fee paid each time person receives medical care
Where can you get insurance? - Answer -group insurance: employee offers plan to workers,
share cost of premiums
-individual insurance: purchase plan directly from insurance company, pay own premiums
options available - Answer -can choose provider
-deductible and co-insurance
, -patient must file an insurance claim for each service themselves and pay the doctor's office for
treatment at time of services
managed care plans: - Answer -"network" of providers on the plan
-costs lower of use network providers
-no insurance claim forms
-co-pays
HMO(Health Maintenance Organization) - Answer -receive most of care from primary care
doctor
-specialists require a referral
-will only pay for network providers
-pays for routine and preventative care
PPO(Preferred Provider Organization) - Answer -no referrals for specialists
-can use network/non-network providers
-pay more for non-network
Medicare - Answer -fed gov health plan
-health coverage for age 65+ and certain disabilities
-plan A: hospital coverage, no premium
-plan B: physician coverage, premium, optional
-treat patients w/ ADLs
Medicaid - Answer -fed gov health plan
-administered by states
-covers those w/ low income and disabled
- eligibility and benefits vary by state
SCHIP/CHIP(State Children's Health Insurance Program) - Answer -state medical coverage for
low income children who don't qualify for Medicaid
worker's compensation - Answer -covers medical care for on-the-job injuries
-covers part of wages lost due to injury
-cost shared by state and employee
