Chapter 12 - Medical Plans Flashcards
If a new employee is eligible, under HIPAA regulations, the new employer must offer coverage on a ___________ _______ basis
If a new employee is eligible, under HIPAA regulations, the new employer must offer coverage on a GUARANTEED ISSUE basis
What is a managed care health care plan?
It is a system of delivering health care and health care services, characterized by arrangements with selected providers, programs of ongoing quality control and utilization review and financial incentives for members to use providers and procedures covered by the plan (to control health care expenses).
Under HIPAA, protected information includes what?
All individually identifiable health information held or transmitted by a covered entity or its business associate in any form or media, whether electronic, paper or oral. This is called protected health information (PHI)
A medical insurance plan in which the health care provider (The Doctor) is paid a regular fixed amount for providing care to the insured and does not receive any additional amounts of compensation dependent upon the procedure performed is called what?
Prepaid plan (The Dr is on salary)
How is emergency care covered for a member of an HMO?
A member of an HMO can receive care in or out of the HMO service area, but care is preferred in the service area.
Define Deductible
The portion of medical expenses that are paid by the insured each year before the insurance benefits start.
Define Coinsurance
Starts after deductible is met. Insured and Insurer share the costs. Helps keep the cost down by requiring the insured’s participation in the ongoing expense.
Define Stop-Loss Feature
The amount that the insured pays out of pocket during the year. When the insured’s out-of-pocket expenses reach the stop-loss, the insurance company then provides coverage at 100% for the remainder of the year. The expenses that qualify for this limit would be the insured’s portion of the coinsurance and it may or may not include the deductible.
Any family coverage must provide coverage for newborns when?
From the moment of birth. This includes newborns adopopted by the insured, if the insured takes physical custody of the infant upon the infant’s release from the hospital.
What are the types of Medical Insurance Plans? (4)
- Major Medical Insurance (Indemnity Plans)
- Health Care Services Organization (HMOs)
- Preferred Provider Organizations (PPOs)
- Point-of-Service Plans (POS)
What are the features of Major Medical Insurance (Indemnity Plans)? (4)
- High Maximum Limits
- Blanket Coverage
- Deductibles paid up front
- Cost-sharing after meeting deductible
What are the features of Health Care Services Organization (HMOs)? 5
- Preventive Care
- Prepaid basis
- Limited to the service area
- Basic Benefit services: \+Hospital Inpatient \+Physician \+Outpatient Medical \+Preventive \+Urgent Care \+Emergency \+Diagnosis Labratory \+Out-of-Area Coverage
-Optional Benefits: \+LTC \+Nursing services \+Home Healthcare \+Prescription Drugs \+Dental/Vision Care \+Mental Health Care \+Substance Abuse Care
What are the features of Preferred Provider Organizations (PPOs)? 3
- Physicians are paid on a fee for service basis
- No PCP referrals
- Members can use any physician they choose but are encouraged to use approved physicians who have previously agreed upon fees.
What are the features of Point-of-Service Plans (POS)? 3
- Combination of HMO and PPO plans
- Employees not locked into one plan, allowed to choose depending on the need for medical services
- Non-member physicians are paid service fee, the patient pays higher coinsurance.
What are the types of Cost Saving Services? (7)
- Preventive Care
- Hospitalization Alternatives
- Second Opinions
- Preadmission Testing
- Catastrophic Case Management
- Risk Sharing
- High Quality of Care
