Chapter 12 Flashcards
Health Insurance
Protection against the financial consequences of poor health
Medical Expense Insurance
Protection against financial losses that result from medical bills because of an accident or illness
Major Medical Insurance
A medical insurance plan designed to provide substantial protection against catastrophic medical expenses. There are few exclusions and limitation, but deductibles and coinsurance are common
Preexisting-Conditions Provision
A provision that excludes coverage for a limited period of time for a physical or metal condition for which a covered person in a benefit plan received treatment or medical advice within a specified time period before becoming eligible for coverage
Dedecutible
The initial amount of portion of covered losses that is borne by the insured, rather that by the insurance company
Common Accident Provision
A provision in a major medical expense contract whereby if two or more members of the same family are injured in the same accident
Coinsurance (Medical Expense Insurance)
The percentage of covered expenses under a medical insurance plan that is paid by the insurance company once a deductible is satisfied. Eighty percent is common.
Stop-Loss Limit
The maximum amount of out-of-pocket medical expenses that a covered person must pay in a given period (usually 1 year). After this limit is reached, future co payments and deductibles are waived for the remainder of the period.
Preadmission Certification
A requirement under many medical expense plans that a covered person or his or her physician obtain prior authorization for any non emergency hospitalization
Second Surgical Opinion
A cost-containment strategy under which covered person are encourages or required to obtain the opinion of another physician after certain categories of surgery have been recommended. If a second opinion is mandatory, benefits are reduced if the second opinion is not obtained. Benefits are usually provided for the cost of a third opinion if the opinions of the first two physicians are in disagreement
Extended Care Facility
A health care facility for a person who no longer requires the full level of medical care provided by a hospital but does need a period of convalescence under supervised medical care. Also known as a skilled-nursing facility.
Home Health Care
Medical Care that is received at home. Care is usually part-time and performed under a plan prescribed by a physician
Hospice Care
A health Care facility or service that provides benefits to terminally ill persons. The emphasis is on easing the physical and psychological pain associated with dying rather than on curing a medical condition
Birthing Center
A facility, separate from a hospital, designed to provide a homelife atmosphere for the delivery of babies. Deliveries are performed by nurse-midwives, and mothers and babies are released shortly after birth.
Managed Care
A process to deliver cost-effective health care without sacrificing quality or access. Common characteristics include controlled access to providers, comprehensive case management, preventive care, risk sharing, and high-quality care.
Health Maintenance Organization (HMO)
A managed system of health care that provides a comprehensive array of medical services on a prepaid basis to voluntarily enrolled persons living within a specific geographic region. HMOs both finance health care and deliver health services. There is an emphasis on preventive care as well as cost control
Preferred-Provider Organization (PPOs)
Benefit Plan that contracts with preferred providers to obtain lower-cost care for plan members. Also refers to health care providers that contract with employers or others to provide medical care services at a reduced fee.
Exclusive-Provider Organization (EPO)
A variation of a PPO in which coverage is not provided outside the preferred-provider network except in those infrequent cases where the network does not have an appropriate specialist
Point-of-Service (POS) Plan
A hybrid arrangement that combines aspects of a traditional medical expense plan with an HMO or a PPO. At the time of medical treatment, a participant can elect whether to receive treatment within the plan’s network or outside the network.
Consumer-Directed medical Expense Care
An approach to medical expense insurance that gives employees increased choices and responsibilities involving their health care
High-Deductible Health Plan
Medical Expense plan with a deductible as high as $5K or more. The employer contributes a lower or equal amount to a savings account from which employees can pay medical expenses not covered because of the deductible.
Defined-Contribution Medical Expense Plan
A plan under which the employer makes a fixed-dollar contribution that an employee can use toward paying the cost of medical expense coverage, regardless of premium
Health Reimbursement Arrangement (HRA)
An account funded with employer dollars from which an employee can withdraw amounts to pay medical expenses that are not covered under a high-deductible medical expense plan
Carve-Out (Medical Expense Insurance)
Coverage under a medical expense plan that has been singled out for individual management by a party other than the employer or the employee’s primary health plan provider
