Question 38

The covered person normally does not receive reimbursement for the service direct from the insurer.

In a managed care plan, the covered person typically does not handle reimbursement directly from the insurer, as services are usually paid directly to the provider by the insurance company.

A) the covered person normally receives reimbursement for the service direct from the insurer.

This statement is incorrect because, in managed care plans, the payment structure is designed so that the insurer pays the healthcare providers directly, rather than reimbursing the covered individuals. Therefore, this option does not apply to the payment of claims.

B) it is generally not required that covered persons file claim forms.

This statement is correct, as managed care plans often streamline the process by not requiring covered persons to file claim forms, since the providers generally handle claims directly with the insurer.

C) a covered person may be responsible for an increased co-payment if they visit a non-network provider.

This statement is also correct. Many managed care plans impose higher co-payments for services received from non-network providers as a financial incentive to use in-network services.

D) reimbursement may be denied if a covered person visits a specialist without a required referral.

This is correct as well. Managed care plans often require referrals to see specialists, and failing to obtain one can result in denial of reimbursement for services rendered.

Conclusion

Option A is definitively the correct answer because it contradicts the typical operational structure of managed care plans, which involve direct payments to providers rather than reimbursements to covered persons. All other options accurately reflect aspects of managed care claim payments, confirming that they apply while option A does not.