Chapter 9: Insuring Your Health Flashcards
Health insurance costs are rising.
true
Health insurance plans are separated into 2 categories. What are they?
- private plans
- government plans
What are the 2 types of private health insurance plans?
- indemnity (fee-for-service) plans
- managed care plans
a contract between a group and a healthcare provider.
group health insurance
a health insurance plan where the healthcare provider is separate from the insurer and the plan pays 80% of medical expenses and the insured pays the other 20%.
traditional indemnity (fee-for-service) plans
the amount that an insurance company pays on a traditional indemnity plan is based on the…
usual, customary, reasonable (UCR) charges.
health insurance plan where users contract with and make monthly payments directly to the organization that provides health care services.
managed care plans
under managed care plans, the insured only pays a co-payment for office visits and medication.
true
- health maintenance organization (HMO)
- preferred provider organization (PPO)
- exclusive provider organization (EPO)
- point-of-service (POS) plan
These are types of what kind of private health insurance plan?
managed care plans
managed care plan that consists of an organization of hospitals, physicians, and other healthcare providers that provide comprehensive health care services to its members.
health maintenance organization (HMO)
what are the 2 types of HMOs?
- group HMO
- individual practice association (IPA)
type of managed care plan where insurance company contracts w/ a network of physicians and hospitals that agree to accept negotiated fee for services.
preferred provider organization (PPO)
type of managed care plan that contracts w/ medical providers to offer services to members at reduced costs, but reimburses members only when affiliated providers are used.
exclusive provider organization (EPO)
type of managed care plan that is a hybrid form of HMO that allows members to go outside of the HMO network for care.
point-of-service (POS) plan
type of managed care plan that consists of prepaid hospital and medical expense plans.
Blue Cross/Blue Shield Plans
what are the 3 types of government health care plans?
- medicare
- medicaid
- workers’ compensation insurance
Pre-existing Condition Insurance Plans (PCIPs) provided health coverage to U.S. citizens who had been denied health insurance coverage because of a pre-existing condition prior to what act?
Affordable Care Act
type of government health insurance plan that is administered by the social security administration for those over 65 or who are disabled.
medicare
medicare provides:
1. basic hospital insurance (Part A)
2. supplementary medical insurance (SMI) program (Part B)
3. medicare advantage plans (Plan C)
4. prescription drug coverage (Part D)
true
government health insurance plan that is state-run public form of assistance program providing health insurance benefits to those who are unable to pay for health care.
medicaid
government health insurance plan that compensates for workers who are injured on the job or become ill through work-related causes.
workers’ compensation insurance
the Patient Protection and Affordable Care Act and the Reconciliation Act of 2010 is also called what?
the Affordable Care Act (ACA)
- reduce the number of uninsured citizens in the U.S.
- reduce the increases in health care costs
These are the goals of what act?
affordable care act (ACA)
- ambulatory patient services
- emergency services
- hospitalization
- maternity/newborn care
- mental health and substance use disorder services
- prescription drugs
- rehabilitative and habilitative services/devices
- laboratory services
- preventive and wellness services and chronic disease management
- pediatric services
These are what?
benefits of the Affordable Care Act (ACA)
- Cover pre-existing conditions
- parents must have the option to carry children on their plan until 26
- lifetime dollar limits on total coverage are prohibited
- plans must cover preventive care and medical screenings
- insurers must spend 80% of premiums on claims
These are what?
features on the Affordable Care Act (ACA)
people need health insurance to cover expenses for medical care and rehabilitation and a loss of income or household service.
true
health insurance plans should incorporate risk avoidance, loss prevention and control, as well as risk…
assumption.
high-deductible health insurance policies w/ tax-free health reimbursement accounts (HRA) or a health savings account (HSA).
consumer-directed health plans
when you lose your job, a “qualifying life event” allows you to obtain health insurance under what act?
COBRA
what prohibits insurance companies from varying rates based on health status or claims history?
community rating approach to health insurance premium pricing
why should you determine gaps in health insurance coverage?
so you can find a way to fill them
what are the 3 types of medical expense coverages?
- hospitalization
- surgical
- physician
insurance policy that reimburses you for the cost of a hospital stay (includes room rate and ancillary services).
hospitalization insurance policy
insurance that covers costs of surgery.
surgical expense insurance
insurance that covers costs of visiting a dr’s office or a dr’s hospital visits, including consultations, imaging, and lab tests.
physician expense insurance (regular medical expense insurance)
plans that provide broad coverage for nearly all types of medical expenses from illnesses and/or accidents.
major medical plans
insurance that combines basic hospitalization, surgical, and physician expense coverage w/ major medical protection w/ a low deductible.
comprehensive major medical insurance
insurance that covers necessary dental care and some dental injuries from accidents.
dental insurance
what are the 3 limited-peril policies mentioned in the textbook?
- accident policies
- sickness polices
- hospital income policies
limited-peril policy that pays a specified sum to the insured injured in a certain type of accident.
accident policies
limited-peril policy that pays a specified sum for a named disease.
sickness policies (dread disease policies)
limited-peril policy that guarantees a specific daily, weekly, or monthly amount when the insured is hospitalized.
hospital income policies
what are the 2 categories of policy provisions?
- terms of payment
- terms of coverage
- deductibles
- participation (co-insurance)
- internal limits
- coordination of benefits provision
These are a part of?:
(a) terms of payment
(b) terms of coverage
(a) terms of payment
deductibles must be paid by insured before insurer pays anything on policy.
true
the participation clause stipulates that the company pays some portion of the amount of the covered loss in excess of the deductible.
true
controls the amounts paid for certain specified expenses.
internal limits
coordination of benefits prevents you from collecting more than 100% of covered charges by collecting benefits from more than 1 policy.
true
- persons/places covered
- cancellation of policy
- pre-existing conditions
- pregnancy/abortion
- mental illness
- rehabilitation coverage
- continuation of group coverage
These are:
(a) terms of coverage
(b) terms of payment
(a) terms of coverage
what does COBRA stand for?
Consolidated Omnibus Budget Reconciliation Act
- preadmission certificate
- continued stay review
- second surgical opinions
- waiver of co-insurance
- limitation of insurer’s responsibility
What are these referred to as?
cost containment provisions
