Chapter 03 Flashcards
Earned Premium
Portion of a premium for which protection has already been given
Unearned Premium
Portion of a premium for which policy protection has not yet been given
Service Area
The primary geographical area of coverage and service provided by a Health Maintenance Organization (HMO)
Payment Structure: Blanket Payment
Maximum dollar limit set, with no itemizing of costs, used for groups covered
under a blanket policy for a specified period or event.
(sports or events)
Payment Structure: Scheduled Payment
A health plan with limits as to what will be paid for covered expenses. most associated with covering day to day losses based on a specified (universal) or flat dollar amount. Scheduled benefit plans are not designed to cover catastrophic losses and have
limited annual benefits.
Payment Structure: Cash or Indemnity Payment
Pays a specified daily amount up to the stated
maximum number of days, or even lifetime. Benefits often double or triple while an insured is
confined in an intensive care unit.
Payment Structure: Fee-for-Service
Provides a separate payment to a healthcare provider for each medical service
received by a patient.
Payment Structure: Prepaid
Medical benefits are provided to a subscriber in exchange for predetermined monthly
premiums paid in advance.
Payment Structure: Usual, Customary, Reasonable
Benefits are not scheduled, but are based on the
average fee charged by all providers in a given geographical area.
Payment Structure: Lifetime Limit
maximum a policy will pay for covered losses during the lifetime of an
insured.
Payment Structure: Annual Limit
maximum a policy will for covered losses per year
Payment Structure: Per-Cause
maximum a policy will pay for covered losses per claim.
Blues
Negotiate price with doctors
prepaid plans, with plan subscribers paying a set fee, usually
monthly, for the services of doctors and hospitals at a predetermined price (negotiated fee).
Not for profit, special regulation
HMOs
Subscribers; Must visit providers within a service area; Providers are paid capitalization fee per subscriber; Preventative care with primary physician; no claims, bills, or deductibles; copay for admin fees; emergency allows for outside network providers; Gatekeeper must approve specialist visit;
HMO: Group Model
independent medical group to provide a variety of medical services to subscribers.
HMO: Staff Model (Closed-Panel)
Contracting physicians are paid employees working on the staff of the HMO.
HMO: Independent Practice Association (IPA) Model (Open-Panel)
Health Maintenance Organizations
maximum freedom of choice of physicians and locations
because the HMO is allowed to contract with a network of independent physicians who are part of an independent practice association. Physicians operate out of their own private offices and subscribers may be individuals the physicians were already treating.
PPOs
Preferred Provider Organizations
Subscribers have more choices among doctors and hospitals under a PPO arrangement. Subscribers
can choose a preferred provider or out of network provider. If an out-of-network provider is utilized,
the PPO pays a reduced amount and the subscriber will have a larger out-of-pocket cost.
Exclusive Provider Organization (EPO)
seek treatment from a network provider.
Unlike an HMO, use of a primary care physician and referral to a specialist are not required
Point of Service (POS)
These Plans combine PPO and HMO benefits.
Basic Medical Expense
Pays for office visits, nonsurgical doctor visits, diagnostic x-rays,
laboratory charges, ambulance, and nursing expenses when not hospitalized.
Basic Hospital Expense
Pays for a hospital room and board (semi-private) with a daily limit
of coverage. Miscellaneous hospital expenses may also be provided
Basic Surgical Expense
– Pays surgeon and anesthesiologist fees for the cost of a surgical
procedure
“First Dollar” coverage.
From the start of the event. They pay the 1st dollar up to a specified limit. If a surgery is not listed in the policy, the company
will pay based on the coverage of a comparable surgery.
Major Medical Expense
catastrophic and/or prolonged injury
or illness
Stop-Loss Provision
A maximum dollar limit set on
the coinsurance to limit the out-of-pocket expense that an insured can incur in a policy
year.
Common Accident Deductible
If several family members are injured in the same
accident, only one deductible is applied
Carryover Provision
Accidents in the last three months of the year will be used to the next year’s deductible if the current year’s deductible was not reached
Supplemental Major Medical Policy
Once the Basic Plan benefits are exhausted, a <b>Corridor</b> Deductible is required to be paid before the start of coverage under the Supplemental Major Medical plan.
Comprehensive Major Medical Policy
This policy requires an initial Flat Deductible that is paid before the Basic plan begins to provide coverage.
Newborn Infant Coverage
insured’s newborn child from the moment of birth
Adopted children are covered at the date of placement
for adoption.
. Notification of birth or adoption
and payment of the required premium must be within a month (30-31 days)
Limited Accident
Such as travel, is not renewable
Endodontics
Services covering dental pulp care and root canals
Orthodontics
– Services for teeth alignment and other irregularities of the teeth
Periodontics
Services for the treatment of gum problems and disease
Prosthodontics
Services provide bridgework and dentures
Restorative Care
– Services to restore the functional use of natural teeth
Oral Surgery
Surgical treatment of diseases, injuries and jaw defects
Exclusions
■ Purely cosmetic services (unless necessitated by an accident)
■ Replacement of prosthetic devices
■ Duplicate dentures or prosthetic devices
■ Oral hygiene instruction or training
■ Occupational injuries covered by Workers’ Compensation
■ Services furnished by or on behalf of government agencies
■ Certain services that began prior to the date of coverage
