Chapter 11 Flashcards
Document issued to provider by department of ins that allows insurer to transact biz in this state
Enrollee
Non renewal
Certificate of authority
Certificate of authority
Policy termination at its expiration date
Indemnity
Cancellation
Prepaid basis cancellation
Nonrenewal
Nonrenewal
Provide medical and hospital benefits in form of service rather than dollars
Subscriber
Enrollee
Nonrenewal
Prepaid basis plan
Prepaid basis plan
Does not use deductibles and coinsurance provisions; stress preventive care as method to reduce Ned for expensive hospital care
HMO
Network model
Group model
HMO
Which plan requires no deductible
Medicare part a
Ppo
HMO
HMO
Primary difference between hmo network models and hmo group models
Group model hmo contracts with multiple physicians in diff network territories
Network model hmo contracts wit multiple physician groups to provide services to members
Group model hmo requires members to meet a deductible prior to the policy paying benefits
Network model hmo contracts with multiple physician groups to provide services to members
HMOs contract with multiple physician groups to provide services to members
Group model hmo contracts with multiple physicians in diff network territories
Group model hmo requires members to meet deductible prior to policy paying benefits
Network model hmo contracts with multiple physician groups to divide services to members
Hmo
Coverage is primarily provided on prepaid basis
Insureds may choose any out of network physician
Insureds are required to pay annual deductible
Hmo may be cancelled for any reason at discretion of insurer
Coverage primarily provided on a prepaid basis
In hmo primary care physician is called a
Gatekeeper
Which provides health ins on prepaid basis where periodic membership fees are paid in exchange for medical services
Ppo
Hra
Hmo
Hmo
Specific dollar amount or percentage of cost of care paid by member
Copayment
Cost share
Prepayment
Copayment
Following included in evidence of coverage for hmo except
Schedule of benefits
Agent’s name and license number
Toll free telephone number
Agent’s name and license number
Hmo enrollee must be provided
Certificate of authority
Evidence of coverage
Buyer’s guide
Evidence of coverage
Network model hmo contracts with
Multiple physician groups to provide services to members
Group model hmo contract with
A Single multi specialty medical group
Where in the policy must the hmo insurer provide info about hmo’s name address and toll free number
Policy appendix
Buyer’s guide
Face page
Face page
Most hmo operate through what type of system
Individual subscribers
Group formed principally for purpose of obtaining hmo coverage
Group enrollment system either at their place of employment or as a member of association
Group enrollment system either at their place of employment or as a member of an association
HMOs that contract with outside physicians to provide health care service to their subscribers compensate those providers on a
Capitation basis
More expensive basis
Medicare allowable basis
Capitation basis
Most HMOs operate through
Individual subscribers
Individual fee for service system
Group enrollment system either at their place of employment or as member of an association
Grou penrollment system either at their place of employment or as a member of an association
All following are grounds for cancellation of hmo EXCEPT
Nonpayment of premium
Not residing in hmo service area
Misconduct
Misstatement of age on app
Misstatement of age on app
Hmo policy may be cancelled or renewed if insured does not live in hmo service area
Reaches 60
Removes coverage for dependents
Does not reside in hmo service area
Does not reside in hmo service area
Re notice of cancellation how soon can hmo terminate coverage for misconduct detrimental to delivery of services
Immediately
10 days
15 days
Immediately
