Health Insurance Policies Flashcards
6 cards from real Life and Health California Exam practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Health Insurance Policies flashcards as text
A Preferred Provider Organization (PPO) differs from an HMO primarily because:
Answer: PPO members can see out-of-network providers at a higher cost
Unlike HMOs, PPOs allow members to use out-of-network providers, though doing so results in higher out-of-pocket costs.
Under a Health Maintenance Organization (HMO), which of the following best describes the role of the primary care physician (PCP)?
Answer: The PCP acts as a gatekeeper coordinating and authorizing specialist referrals
In an HMO, the PCP coordinates all of the member's care and must provide referrals before the member can see a specialist.
What is the purpose of the 'stop-loss' provision in a major medical policy?
Answer: It limits the insured's total out-of-pocket coinsurance to a specified maximum
The stop-loss (out-of-pocket maximum) provision caps the insured's coinsurance payments so that once reached, the insurer pays 100% of remaining covered expenses.
Under California law, what is the minimum grace period for health insurance policies paid on a monthly basis?
Answer: 31 days
California law requires a minimum 31-day grace period for monthly health insurance premiums before the policy lapses.
A health insurance policy that covers all medical expenses—hospital, surgical, and physician—under a single plan is known as:
Answer: Comprehensive major medical policy
A comprehensive major medical policy combines hospital, surgical, and physician expense coverage into one plan with a single deductible and coinsurance requirement.
Which of the following is NOT typically excluded from a standard individual health insurance policy?
Answer: Treatment for a pre-existing condition after the waiting period expires
After the applicable pre-existing condition waiting period expires, treatment for that condition is a covered benefit under the policy.