5/H - Health Insurance Flashcards
Evidence of Coverage
Health Insurance
A plan that covers and shares expenses associated with health care
- Exact provisions of coverage found in health insurance contract
- Health insurance contract = Evidence of Coverage
Deductible, Copayment, Coinsurance
Deductible
The amount the policyholder pays before insurance policy benefits activate
Copayment
The amount the policyholder pays each time she accesses the benefits of a health insurance policy
E.g. Doctor’s visits, filling prescriptions, etc.
Coinsurance payment
A percentage of the total health care expenses that the insured must pay
Out-of-pocket, Network Provider, Capitation
Out-of-pocket expenses
Any deductibles, copayments, and coinsurance that a policyholder pays
Network provider
Member physicians and healthcare facilities contracted to treat an insurer’s policyholders (minimizes healthcare costs)
Capitation
An insurer’s practice of paying a healthcare provider up front in return for the agreement to treat all members of the insurer
Group Health Insurance
- Lower health insurance costs for the employer and employee
- All employees included, regardless of current health status
- Helps eliminate or reduce policy waiting periods
- Coverage often continues even after employees leaves the group
Typically managed by:
- HMO: Health Maintenance Organization
- PPO: Preferred Provider Organization
Individual Health Insurance
There are two ways for an individual to get Comprehensive or Catastrophic Insurance:
- Purchase directly from an insurance provider
- Purchase through HMO, PPO, or POS
Drawbacks of Individual Health Coverage
- Individual Health Insurance can be extremely expensive
- Insurers previously could deny coverage if the applicant has an extensive history of medical problems
- Now, the Affordable Care Act prohibits insurers from denying coverage for pre-existing conditions
Health Maintenance Organization (HMO)
Managed care insurer providing health insurance through a provider network
- HMO members choose an approved primary care physician for preventative care and coordination of all other medical care
- The primary care physician approves medical specialist visits or hospitalization for the member only if the HMO deems it to be “necessary treatment”
HMO continued
More features of HMO
- Broad range of comprehensive medical care
- Few exclusions and minimal deductibles
- Restricts members from choosing care providers outside of the network
- Promotes health programs in hopes of minimizing their health care costs
Preferred Provider Organization (PPO)
Exactly like HMO except:
- Members may choose healthcare outside of the Network Provider
- Members pay the difference between network coverage cost and non-network costs
Advantages of Preferred Provider Organization (PPO)
Benefits for PPO members:
- Access to PPO network care at a very low cost
- Flexibility of choosing own medical care, if willing to pay substantially more out-of-pocket
- Coverage for emergency medical services at both PPO and non-PPO hospitals
Point of Service Plans (POS)
POS combines qualities of HMO and PPO plans:
- Members choose a primary physician who becomes their “point of service”
- Plan can cover visits in or out of network, based on the primary physician’s recommendation
- POS can refuse payment if the member sees a specialist without the primary physician’s consent
Major Medical Plans
- High medical coverage limits
- Does not restrict the insurer to a network
- Risk of major out-of-pocket costs
- High deductible, and significant coinsurance percentage requirement
Exclusions:
- Pregnancy and childbirth
- Self-inflicted injuries
- Mental illness
- Cosmetic surgeries
- Injuries applicable to WC
Surgical and Hospital Insurances
Surgical Expense Insurance: compensation for physician costs associated with surgical procedures
Hospital Indemnity Insurance: coverage providing a flat amount of indemnification per day for hospitalization
Hospitalization Expense Insurance: coverage for various hospital expenses (room and board, medical supplies, lab fees, nursing care, etc.)
Accident Insurance
Covered expenses:
- Expenses associated with a covered accident (impact injuries, fractures, burns, dismemberment, dislocations, etc.)
- Ambulance and emergency room/intensive care expenses, hospital costs
- Loss of income and a death benefit if injuries prove fatal
Accident Insurance Exclusions
- Self-inflicted injuries
- Injuries occurring while under the influence
- Injuries received in the commission of a crime
- Disease and bacterial infections
