chapter 15 Flashcards
Characterized by limited benefit periods and relatively low coverage limits.
basic medical expense insurance
health insurance policy that provides broad coverage and high benefits for hospitalization, surgery, and physician services. Characterized by deductibles and coinsurance cost sharing.
major medical expense policy
amount of expense or loss to be paid by the insured before a health insurance policy starts paying benefits.
deductible
a stated dollar amount that applies to a covered loss (e.g. $500). This deductible is applied per occurrence, per insured individual.
flat deductible
comes in to play when a major medical policy is supplementing basic coverage that contains no deductible
corridor deductible
used when a major medical plan is supplementing basic coverages
integrated deductible
insured must satisfy a deductible for each accident or illness.
per-cause deductible
insured only has to meet the deductible amount once during the benefit period.
all-cause deductible
allows an insured to defer current health charges to the following year’s deductible instead of the current year’s deductible.
carryover provision
is the principle under which the company insures only part of the potential loss, the policyowners paying the other part
coinsurance
is designed to stop the company’s loss at a given point, as an aggregate payable under a policy, a maximum payable for any one disability, or the like; also applies to individuals, placing a limit on the maximum out-of-pocket expenses an insured must pay for health care, after which the health policy covers all expenses.
stop-loss
reimburse employees for out-of-pocket medical expenses and individual health insurance premiums. Unused amounts may be carried forward for reimbursement in future years. Reimbursements may be tax-free if the employee paid for qualified medical expenses or a qualified medical plan.
health reimbursement arrangements
tax-advantaged accounts that can be set up through a cafeteria plan of an employer. An FSA allows an employee to set aside a portion of earnings to pay for qualified medical expenses (such as prescription medication) as established in the cafeteria plan
flexible saving/spending account
forms of health insurance providing a stipulated daily, weekly, or monthly indemnity during hospital confinement;
hospital indemnity policies
restrict benefits to specified accidents or diseases, such as travel policies, dread disease policies, ticket policies, and so forth.
limited benefit policies
provide a variety of benefits for a specific disease such as cancer or heart disease. Benefits are usually paid as a scheduled, fixed-dollar amount for specified perils or medical procedures such as hospital confinement or chemotherapy
limited risk policies
are an insurance product in which the insurer is contracted to typically make a lump sum cash payment if the policyholder is diagnosed with one of the specific illnesses on a predetermined list as part of an insurance policy.
critial illness poliies
cover hospital room and board, miscellaneous hospital expenses (such as lab and x- ray charges), medicines, use of operating room, and supplies. These expenses are covered while the insured is confined in a hospital.
hospital expense policies
cover expenses for occupancy of the room and bed, general nursing care, food and beverages, and personal hygiene items.
hospital room and board benefits
These policies pay for the costs of surgeons’ services, whether the surgery is performed in or out of the hospital. Coverage includes surgeon’s fees, anesthesiologist, and the operating room.
surgical expense policies
every surgical procedure is assigned a dollar amount by the insurer.
surgical schedule approach
similar to the surgical schedule method. The difference is that instead of a flat dollar amount being assigned to every surgical procedure, a specified set of units is assigned.
relative value approach
maximum amount an insurer will consider eligible for reimbursement under a health insurance plan. what is deemed reasonable and customary for the geographical part of the country where the surgery was performed
usual, customary, and reasonable approach (UCR)
combines the features of basic expense coverage and major medical coverage, sold as one policy. Cover practically all medical expenses, hospital, physicians, surgical, nursing, drugs, laboratory tests, etc.
comprehensive major medical
