HMO, PPO, HDHP, ACA essential health benefits, disability income definitions and provisions.
About this set
40 basic cards for Licensing exam Insurance. It opens with "In an HMO, what is the primary role of the primary care physician?" and "Can an HMO member see a specialist without a referral from their primary care". Study it alongside the other Licensing exam sets below.
40 cards · basic cards · AI-written, checked twice. Edit anything.
- In an HMO, what is the primary role of the primary care physician?
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Acts as a gatekeeper controlling access to specialists and coordinating member care- Can an HMO member see a specialist without a referral from their primary care physician?
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No, specialists generally require a referral to be covered- Are emergency services at out-of-network hospitals covered by an HMO?
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Yes, emergency services are typically covered without prior referral- How do HMO copays typically compare to PPO copays?
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HMO copays are generally lower due to the restricted network model- What is the primary coverage restriction of an HMO?
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Members must use in-network providers except in emergencies- What does PPO stand for?
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Preferred Provider Organization- Can PPO members see specialists without a referral?
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Yes, PPO members can access specialists directly- How does a PPO member's coverage work with out-of-network providers?
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Out-of-network care is covered but at higher cost-sharing (higher deductible and coinsurance)- What is the main advantage of a PPO compared to an HMO?
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Greater flexibility in choosing providers without needing referrals- What does HDHP stand for?
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High Deductible Health Plan- What type of account is an HDHP eligible to pair with?
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Health Savings Account (HSA)- Why are HDHP premiums typically lower than other health plans?
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The high deductible shifts more cost responsibility to the individual- What term describes an HDHP's emphasis on individual decision-making?
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Consumer-directed health plan- What is one ACA-mandated essential health benefit?
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Ambulatory patient services (outpatient care)- Which ACA essential benefit covers emergency department services?
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Emergency services
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