Ch 5 Medical Plans Part II Flashcards
What type of health insurance plans cover all accidents and sicknesses that are not specifically excluded in the policy?
Comprehensive plans
What type of injuries and services will be excluded from major medical coverage?
Injuries caused by war, intentionally self-inflicted injuries, injuries covered by Worker’s Compensation, regular dental/vision/hearing care, custodial care, and elective cosmetic surgery
What are the two types of flexible spending account?
Health care accounts and dependent care account
What are the tax implications for contributions to a health savings accounts by the individual insured?
Contributions are tax deductible
What are the three types of basic medical expense insurance?
Hospital, surgical and medical
What are the five basic characteristics of managed care plans?
- controlled access to providers
- comprehensive case management
3 preventative care
4 risk sharing
5 high quality care
What is the purpose of the coinsurance provision in health insurance policies?
To prevent over utilization of the policy benefits
What is the main difference between coinsurance and co-pay?
Co-pay is a set dollar amount; coinsurance is a percentage of the expenses
What is the main principle of an HMO plan?
Preventative care
In what type of health plans are providers paid for services in advance, regardless of the services provided?
Prepaid plans
What provision provides for the sharing of expenses between the insured and the insurance company?
Coinsurance
When are newborns covered in individual health insurance policies?
From the moment of birth
How are HMO territories typically divided?
Geographic areas
What are usual/reasonable and customary charges based on?
Average charge for a given procedure in the specific geographic area
Who chooses a primary care physician in an HMO plan?
The individual member
Under what type of care do insurers negotiate contracts with healthcare providers to allow subscribers access to healthcare services at a favorable cost?
Preferred provider organization (PPO)
What is the purpose of managed care health insurance plans?
To control health insurance claims expenses
Why do HMOs encourage members to get regular check ups?
To help catch health problems early when treatment has the greatest chance for success (preventative care)
Can an insured who belongs to a POS plan use an out of network physician?
Yes, but the co-pays and deductibles may be higher
What is the role of the gatekeeper in an HMO plan?
To control cost for the services of specialists
How can an HMO member see a specialist?
Referral by the primary care physician
What is a fee-for-service health plan?
Under a fee for service plan, providers receive payments for each service provided
