Ch. 5 - Medical Plans Flashcards
A reuqest for a higher authority to review the decision
Appeal
covers member of a particular group when they are participating in a particular activity, without namin individual insureds (such as students, passengers, or 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 or group of physicians (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
nonrenewal
amounts an insured must pay for coinsurance and deductibles before the insurer will pay its portion
out-of-pocket expenses
the amount that 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
Amounts an insured must pay for coinsurance and deductibles before the insurer will pay its portion.
Out-of-pocket expenses
The act of 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
What are the tax implications for contributions to a health savings account?
Contributions are tax deductible.
What are the two types of flexible spending accounts?
Heath care accounts and dependent care accounts
What are the five basic characteristics of managed care plan?
- Controlled access to providers
- Comprehensive case management
- Preventive care
- Risk sharing
- High quality care
What is the max age for qualifying for a catastrophic plan.
- Also individuals who cannot obtain affordable coverage may be able to purchase a catastrophic plan to cover essential benefits
Most policies will pay the accidental death benefit as long as the death is caused by the accident and occurs within how many days?
90
What do these basic benefits all have in common?
Hospital inpatient services, physicians services, outpatient medical services, preventive services, emergency services, diagnostic lab services, and out-of-area coverage.
All are considered to be basic benefits of an HMO. Note that rx benefits are not included.
