Chapter 5 Flashcards
Comprehensive Care
Plans that provide coverage for most types of medical expenses; preventive care, routine physicals, immunizations, outpatient services, and hospitalization such as HMO’s
Basic Medical Expense Policies
Low dollar limits and first dollar coverage, but no protection to an individual/family against catastrophic medical expenses that would be financially disastrous
Major Medical Policy
Provides protection against catastrophic loss; uses deductibles and coinsurance to be made affordable
Major Medical Characteristics
High maximum limits; blanket coverage; coinsurance; deductible that is paid up front
Major Medical Exclusions
War injuries; intentional self-inflicted injuries; regular vision/dental/hearing care; custodial care; cosmetic surgery
Major Medical Policy Premiums
Vary depending on deductible amount; coinsurance percentage; stop-loss amount; maximum amount of benefit
Deductible for Major Medical
Higher deductible = lower premium
Stop-Loss
The amount the insured pays out of pocket until reaching the stop-loss which when when the company will provide coverage at 100% of eligible expenses such as insured’s coinsurance and possibly the deductible; high stop-loss = low premium
Major Medical Maximum Benefits
1 million or 2 million; usually lifetime maximums
Health Maintenance Organizations (HMO)
Benefits are in the form of services versus reimbursement for the services of the physician or hospital
HMO Service Area Limits
Limited to those living within certain geographic boundaries
HMO Provider Limits
Care only provided from physicians who agree to a prenegotiated price
HMO Prepaid Basis
The HMO receives a flat amount each month attributed to each member whether they see a physician or not
HMO Main Goal
Reduced cost of health care by utilizing preventive care
HMO Hospital Services
Members provided with inpatient hospital care in/out of service area
HMO Basic Services
Hospital inpatient services; Physicians’ services; Outpatient medical services; Preventive Services; Urgent care services; Emergency care services; Diagnostic laboratory services; Out-of-area coverage
HMO Optional Supplemental Benefits
Long term care, nursing services, home health care, prescription drugs, dental care, vision care, mental health care, substance abuse services
Preferred Provider Organizations (PPO)
A group of physicians and hospitals that provide medical care services at a reduced fee to employers, insurers, and third party organizations
PPO General Characteristics
Paid a fee for service instead of salary; higher out of pocket costs and less coverage is provided when a member uses a physician not on the PPO list
Point-of-Service (POS) Plans
A combination of HMO and PPO plans where a different choice can be made every time a need arises for medical services; provider network controlled by gatekeeping; members can self-refer at increased out of pocket costs but benefits covered are more expensive
Managed Care Plans
Designed to control costs by controlling behavior of plan participants; Preventive care (annual physicals, mammograms, etc.) control length of hospital stay, utilization reviews to improve case management
Utilization Management
A system used to review the appropriateness and efficient allocation of health care services and resources being given or proposed to be given to insured
Prospective Review (Precertification)
Physician submits claim information prior to treatment to know what procedures will be covered at what rate
Concurrent Review
Insured’s hospital stay is monitored to be sure that everything is going as planned
Maternity Benefits
48 hours of inpatient care for normal vaginal delivery; 96 hours for caesarean delivery
PA Mandated Benefits
Group policies must provide alcohol abuse/dependency benefits and serious mental illness; Maternity benefits for hospital stay/adopted children and newborns
HIPAA (Health Insurance Portability and Accountability Act)
Regulates protection for both group health plans and for individual insurance policies
Group Health Plans (HIPAA)
Prohibits discrimination against employees and dependents; allows opportunities to enroll in a new plan to individuals in special circumstances
Individual Policies (HIPAA)
Guaranteed access to individual policies for qualified individuals; guaranteed renewability
HIPAA Eligibility
Cannot establish eligibility rules for enrollment under the plan that discriminate based on any health factor: health status, medical conditions, claims experience, receipt of health care, medical history, genetic information, disability, evidence of insurability
Eligibility to convert from group to individual under HIPAA
18 months of continuous coverage, been covered under a group plan in most recent coverage, not eligible for Medicare/Medicaid, not have any other insurance, apply within 63 days of losing prior insurance
Affordable Care Act (ACA)
Set up a new competitive private health insurance market; keeping premiums low, preventing denials of care and allowing applicants with preexisting conditions to obtain coverage; stabilize budget and economy through reducing the deficit
Affordable Care Act Eligibility
U.S. citizen, national, or lawfully present in the U.S.; live in U.S.; not currently incarcerated, not covered under Medicare
Affordable Care Act premium rates
Depend on geographic rating area; family composition; age; tobacco use
Affordable Care Act Essential Benefits
Hospitalization, maternity, emergency services, wellness, preventive services, chronic disease management
Metal levels
Bronze - 60%, Silver 70%, Gold 80%, Platinum 90%
Affordable Care Act enrollment
November 1st to January 31st
Individual Mandate
All U.S. citizens and legal residents are required to have qualifying health care coverage
