Health Ins Plans Flashcards
Main principle of an HMO plan
Preventative care
What is a fee for service health plan?
Providers receive payments for each service provided
Tax implications for a Health Savings Acct for the individual insured?
Contributions are tax deductible
Type of HI plan that covers all accidents and sicknesses that are not specifically excluded in the policy?
Comprehensive plans
Type of care where insurers negotiate contracts with providers to allow subscribers access to health care services at a favorable cost?
Preferred Provider Organization PPO
Type of injuries and services excluded from major medical coverage?
Caused by war, self inflicted, covered by workers comp, regular dental/vision/hearing care, custodial care, elective cosmetic surgery
Who chooses the primary care doc in an HMO?
The individual member
2 types of flex spending acts?
Health care acct and dependent care acct
Purpose of managed care health ins plan
To control health ins claims expenses
3 types of basic medical expense insurance?
Hospital, surgical, and medical
Why do HMOs encourage members to get regular checkups?
To help catch health probs early when treatment has the greatest chance for success (preventative care)
Can an insured who belongs to a POS plan use an out of network doc?
Yes but the copays and deductibles May be higher
Main diff between coinsurance and copay?
Copay is a set dollar amount, coinsurance is a percentage of expenses
Purpose of the coinsurance provision in HI policies?
Prevent over utilization of the policy benefits
How are HMO territories typically divided?
Geographic areas
Provision that provides for sharing of expenses between the insured and the ins co?
Coinsurance
How can an HMO member see a specialist?
Referral by primary care doc
When are newborns covered in individual HI policies?
From the moment of birth
5 basic characteristics of managed care plans?
Controlled access to providers Comprehensive case management Preventative care Risk sharing High quality care
What are usual/reasonable and customary charges based on?
Avg charge for a given procedure in a specific geographic area
What type of plan are providers paid for services in advance, regardless of service provided?
Prepaid plans
Role of the gatekeeper in HMO?
To control costs for the services of specialists
