Ch 5 Medical Plans Flashcards
A request for a higher authority to review the decision
Appeal
Covers members of a particular group when they are participating in a particular activity, without naming individual insureds (such as students, passengers, sports teams)
Blanket policy
A payment arrangement that pays a physician or group of physicians a set amount for each enrolled person assigned to them, Per period of time, whether or not that person seeks care.
Capitation
A primary care physician (PCP) in an HMO plan
Gatekeeper
Pays health policy benefits to the insured based on a predetermined, fixed rate, regardless of the actual expense incurred
Indemnity plan
Policy termination at its expiration date
Nonrenewable
Amounts and insured must pay for coinsurance and deductible before the insurance will pay its portion
Out of pocket expenses
The active repaying a party who has spent or lost money
Reimbursement
The amount the insured pays out of pocket during the year
Stop loss
A person who signs up for a prepaid health plan, such as an HMO
Subscriber
Higher deductible =
Lower premium
The main foucs for an HMO is:
Preventive care
In an HMO, a ______________ helps control the cost of healthcare by only making the necessary referrals.
gatekeeper
Unlike HMOs, PPOs allow more flexibility between an in-network and out-network providers, in exchange for a higher premium.
True
Non-health withdrawals before age 65 = _________ non-health withdrawals after age 65 = __________.
20% penalty; no penalty.
HRAs allow employees to rollover unused benefits to the following calendar year, in addition to new benefits.
True
The affordable care act requires all individual and group health insurance plans be issued on a guaranteed issue basis.
True
Individual catastrophic plans that cover essential benefits are available for adults under age 30 and individuals who cannot obtain affordable coverage.
True
Under the affordable care act, premium discounts may be awarded to low income individuals, regardless of the chosen metal levels
True
Payments are made continuously, regardless of services provided
Prepaid plans
Limit services to one illness or group of coverage
Specified coverages
Provide coverage for most types of medical expenses
Comprehensive care
State exact coverages under a plan and given costs
Benefit schedule
Major medical insurance (Indemnity Plans)
- High maximum limits
- blanket coverage
- deductibles paid upfront
- cost shared after meeting deductible
Healthcare services organization (HMOs)
- Preventative care
- prepaid basis
- Limited to service area
- Basic benefit services
- optional benefits
Hospital inpatient, physician, outpatient medical, preventative, urgent care, emergency, diagnostic laboratory, out of area coverage
Basic benefit services
Long-term care, nursing services, home health care, prescription drugs, dental/vision care, mental healthcare, substance abuse services
Optional benefits
Preferred provider organizations (PPOs)
- physicians are paid on a fee-for-service basis
- no PCP referrals
- members can use any position they choose but they are encouraged to use approved physicians who have previously agreed-upon fees
Point of service plans (POS)
- combination of HMO and PPO plans
- employees not locked into one plan; allowed to choose depending on the need for medical services
- nonmember physicians are paid service fee; patient pays higher coinsurance
Cost saving services
Preventative care, hospitalization alternatives, second opinion, preadmission testing, catastrophic case management, risk sharing, high quality of care
Claim information submitted before treatment
Perspective review
Claim information submitted after treatment
Retrospective review
Insured’s hospital stay monitored and plan for release
Concurrent review
Managed care
- Financial incentives for using approved providers or procedures
- primary focus of preventative care
Improved case management through utilization review - Control length of hospital stay
Affordable care act
- Mandates preventative, educational, and community-based healthcare
- children are covered until age 26
- coverage of pre-existing conditions
Metal levels/plan covers:
Bronze 60%
silver 70%
gold 80%
platinum 90%
Hospitalization, maternity, emergency services, wellness and preventative services, chronic disease management
Essential benefits
Affordable care act
Basic hospital, surgical and medical policies, as well as major medical policies are considered what type of insurance?
Medical expense insurance
What are some of the characteristics of a major medical expense policy?
High maximum limits, blanket coverage, coinsurance, and deductibles
Preventive care services are a hallmark of what type of health care provider?
Health maintenance organization (HMO)
