Quantum Health Core Training Modules – |\ |\ |\ |\ |\ |\
questions with answers |\ |\
Premium - CORRECT ANSWERS ✔✔The money that the employee
|\ |\ |\ |\ |\ |\ |\ |\ |\
(and typically your employer) pays for access to insurance
|\ |\ |\ |\ |\ |\ |\ |\ |\
coverage. If purchased through the employer, this money is
|\ |\ |\ |\ |\ |\ |\ |\ |\
typically taken directly out of the employee's paycheck per the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
frequency determined by the employer (monthly, bi-weekly,
|\ |\ |\ |\ |\ |\ |\
weekly, etc.) |\
Deductible - CORRECT ANSWERS ✔✔A fixed dollar amount a
|\ |\ |\ |\ |\ |\ |\ |\ |\
covered member is responsible for paying out of pocket during
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the plan year before the insurance begins to pay for covered
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
services. Plans may have both a separate individual and family
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
deductible and may differ for services provided by an INN
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
physician or OON physician. |\ |\ |\
Copay - CORRECT ANSWERS ✔✔A fixed dollar amount a covered
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
member is responsible for paying to the provider at the time of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
service. Copays are mostly used for office visits to the PCP,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
specialist, Urgent Care, and ER, but only if the plan is designed
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
with a copay option.
|\ |\ |\
Coinsurance - CORRECT ANSWERS ✔✔The percentage of costs |\ |\ |\ |\ |\ |\ |\ |\
shared by the patient and the insurance plan typically after the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
member's deductible is met. These amounts can vary based on
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
utilizing an INN provider vs. OON provider. Providers can ask for
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the members portion to be paid at the time of service, but
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
, sometimes is deferred by the provider's office until the claim has
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
been processed and the exact amount identified.
|\ |\ |\ |\ |\ |\
OOP MAX (Out-of-Pocket Maximum) - CORRECT ANSWERS ✔✔The
|\ |\ |\ |\ |\ |\ |\ |\
total maximum amount that a covered member of family
|\ |\ |\ |\ |\ |\ |\ |\ |\
member is responsible for paying out-of-pocket towards medical
|\ |\ |\ |\ |\ |\ |\ |\
services within a calendar or plan year. The out-of-pocket (OOP)
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
expense usually includes the plan deductible, what the member
|\ |\ |\ |\ |\ |\ |\ |\ |\
pays for co-insurance, and (if applicable) copays. Once the OOP
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Maximum has been met, the plan will cover 100% of allowable
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
medical expenses by an INN provider for the rest of the calendar
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
or plan year.
|\ |\
Exclusions - CORRECT ANSWERS ✔✔Healthcare services that are
|\ |\ |\ |\ |\ |\ |\ |\
not covered by the plan.
|\ |\ |\ |\
Benefit Limitations/Maximums - CORRECT ANSWERS ✔✔When
|\ |\ |\ |\ |\ |\
limitations are applied to a plan, the plan will not pay benefits
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
once the limitations is reached, or the criteria is not met.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
(Example: "Covers 60 visits per plan year for physical,
|\ |\ |\ |\ |\ |\ |\ |\ |\
occupational, and speech therapy combined.") |\ |\ |\ |\
Allowed Amount (Network Contracted Rate) - CORRECT ANSWERS
|\ |\ |\ |\ |\ |\ |\
✔✔The maximum amount a provider will be paid for a service.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
The rate is based on their contract with the network. Benefits are
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
paid against the "allowed amount" not the actual "charged
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
amount." INN providers cannot balance bill members for the
|\ |\ |\ |\ |\ |\ |\ |\ |\
difference between the provider's charged amount and the
|\ |\ |\ |\ |\ |\ |\ |\
maximum allowed amount for covered services. |\ |\ |\ |\ |\ |\
questions with answers |\ |\
Premium - CORRECT ANSWERS ✔✔The money that the employee
|\ |\ |\ |\ |\ |\ |\ |\ |\
(and typically your employer) pays for access to insurance
|\ |\ |\ |\ |\ |\ |\ |\ |\
coverage. If purchased through the employer, this money is
|\ |\ |\ |\ |\ |\ |\ |\ |\
typically taken directly out of the employee's paycheck per the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
frequency determined by the employer (monthly, bi-weekly,
|\ |\ |\ |\ |\ |\ |\
weekly, etc.) |\
Deductible - CORRECT ANSWERS ✔✔A fixed dollar amount a
|\ |\ |\ |\ |\ |\ |\ |\ |\
covered member is responsible for paying out of pocket during
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the plan year before the insurance begins to pay for covered
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
services. Plans may have both a separate individual and family
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
deductible and may differ for services provided by an INN
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
physician or OON physician. |\ |\ |\
Copay - CORRECT ANSWERS ✔✔A fixed dollar amount a covered
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
member is responsible for paying to the provider at the time of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
service. Copays are mostly used for office visits to the PCP,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
specialist, Urgent Care, and ER, but only if the plan is designed
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
with a copay option.
|\ |\ |\
Coinsurance - CORRECT ANSWERS ✔✔The percentage of costs |\ |\ |\ |\ |\ |\ |\ |\
shared by the patient and the insurance plan typically after the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
member's deductible is met. These amounts can vary based on
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
utilizing an INN provider vs. OON provider. Providers can ask for
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the members portion to be paid at the time of service, but
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
, sometimes is deferred by the provider's office until the claim has
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
been processed and the exact amount identified.
|\ |\ |\ |\ |\ |\
OOP MAX (Out-of-Pocket Maximum) - CORRECT ANSWERS ✔✔The
|\ |\ |\ |\ |\ |\ |\ |\
total maximum amount that a covered member of family
|\ |\ |\ |\ |\ |\ |\ |\ |\
member is responsible for paying out-of-pocket towards medical
|\ |\ |\ |\ |\ |\ |\ |\
services within a calendar or plan year. The out-of-pocket (OOP)
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
expense usually includes the plan deductible, what the member
|\ |\ |\ |\ |\ |\ |\ |\ |\
pays for co-insurance, and (if applicable) copays. Once the OOP
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Maximum has been met, the plan will cover 100% of allowable
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
medical expenses by an INN provider for the rest of the calendar
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
or plan year.
|\ |\
Exclusions - CORRECT ANSWERS ✔✔Healthcare services that are
|\ |\ |\ |\ |\ |\ |\ |\
not covered by the plan.
|\ |\ |\ |\
Benefit Limitations/Maximums - CORRECT ANSWERS ✔✔When
|\ |\ |\ |\ |\ |\
limitations are applied to a plan, the plan will not pay benefits
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
once the limitations is reached, or the criteria is not met.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
(Example: "Covers 60 visits per plan year for physical,
|\ |\ |\ |\ |\ |\ |\ |\ |\
occupational, and speech therapy combined.") |\ |\ |\ |\
Allowed Amount (Network Contracted Rate) - CORRECT ANSWERS
|\ |\ |\ |\ |\ |\ |\
✔✔The maximum amount a provider will be paid for a service.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
The rate is based on their contract with the network. Benefits are
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
paid against the "allowed amount" not the actual "charged
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
amount." INN providers cannot balance bill members for the
|\ |\ |\ |\ |\ |\ |\ |\ |\
difference between the provider's charged amount and the
|\ |\ |\ |\ |\ |\ |\ |\
maximum allowed amount for covered services. |\ |\ |\ |\ |\ |\
