The following statements are about concepts related to the underwriting function within a health plan. Select the answer choice containing the correct statement.
The process of calculating the appropriate premium to charge purchasers, given the degree of risk represented by the individual or group, the expected costs to deliver medical services, and the expected marketability and competitiveness of the health plan
One of the most influential pieces of legislation in the advancement of managed care within the United States was the HMO Act of 1973. One provision of the HMO Act of 1973 was that it
If left unresolved, member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. In early efforts to manage healthcare costs, traditional indemnity health insurers included in their health pla
The Conquest Corporation contracts with the Apex health plan to provide basic medical and surgical services to Conquest employees. Conquest entered into a separate contract with the Bright Dental Group to provide and manage a dental care program for employee
The National Association of Insurance Commissioners' (NAIC's) Unfair Claims Settlement Practices Act specifies standards for the investigation and handling of claims. The Act defines unfair claims practices and notes that such practices are improper if the
Most contracts between health plans and providers contain a provision which forbids providers from seeking compensation from patients if the health plan fails to compensate the provider because of insolvency or for any other reason. Such a provision is kn
Janet Riva is covered by a traditional indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan.
One factor the Sandpiper Health Plan uses to assess its quality is a clinician's bedside manner, i.e., how friendly and understanding the clinician is, whether the patient feels that the clinician listens to the patient's concerns, how well the clinical
