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IL Life and Health Insurance > Health Policies and Plans > Flashcards

Health Policies and Plans Flashcards

1
Q

“Basic” plans predated…

A

Modern health insurance

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2
Q

Basic plans provided…

A

First dollar coverage, often with no cost-sharing from the patient

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3
Q

Basic plans had…

A

Very low benefit limits by modern standards

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4
Q

Hospital Expense Insurance

A

Covered hospital room and board and other hospital expenses

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5
Q

HEI: Hospital Room and Board

A

Semi-private room and meals; had a certain per-day limit for specified number of days

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6
Q

HEI: Other Hospital Expenses

A

Tests, supplies, medicine, transfusions; often capped at multiple of the per-day limit for room and board

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7
Q

HEI: Had no coverage of…

A

Physician bills or outpatient services, even if care is at the hospital

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8
Q

Surgical Expense Insurance

A

Covers inpatient or outpatient surgery based on type of procedure

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9
Q

Fee Schedule

A

Covered amount for specific surgery will be based on preset max already set by insurer for that procedure, regardless of geography

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10
Q

Reasonable and Customary Charges

A

Covered amount for specific surgery will depend on what most providers typically charge in the area

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11
Q

Patients can be responsible for…

A

Amounts charged beyond fee schedule/reasonable and customary charges

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12
Q

Surgery Second Opinions

A

Some non-emergency surgeries aren’t covered without a second opinion

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13
Q

Surgery Second Opinion: Who will pay for second opinion?

A

Insurer

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14
Q

Surgery Second Opinion: Patient can still get surgery if…

A

2 surgeons disagree with each other

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15
Q

Physicians Expense Insurance

A

Pays for physician charges at hospitals, offices, etc.

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16
Q

Physicians Expense Insurance capped at…

A

Certain dollar amount and/or number of visits

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17
Q

Major Medical Insurance

A

Pays for hospital, surgical, and physician charges under the same policy

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18
Q

MMI: Has high dollar limits but…

A

Cost-sharing

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19
Q

MMI: HAs annual out-of-pocket limits per…

A

Year

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20
Q

Major Medical Insurance was originally bought as…

A

Supplemental for basic expense policies

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21
Q

MMI: After basic policies were exhausted, consumer…

A

Paid “corridor deductible” before major medical kicked in

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22
Q

Major Medical Insurance is now bought…

A

Stand alone, with a deductible at the start

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23
Q

Deductible

A

Amount of otherwise insured loss that must be paid out of pocket before benefits will kick in

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24
Q

Deductible is typically…

A

Per year or per cause

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25
Q

Per Cause

A

Might apply after 30 days of not needing similar care

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26
Q

Per Calendar Year

A

Might allow for a “carryover provision” for amounts paid in last 3 months of previous year

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27
Q

Family Deductible

A

Might prevent all members from having to meet their own deductible after a few members have met their own deductible

28
Q

Coinsurance

A

Splits the cost of medical bills on a percentage basis

29
Q

Common coinsurance percentage

A

80% by insurer, 20% by insured

30
Q

Coinsurance is applied…

A

After deductible is met

31
Q

Copayment

A

Paid by insured as a flat fee per service; often due at time of service

32
Q

Out of Pocket Limit

A

Caps the amount the insured must pay per year in coinsurance fees, deductibles, and sometimes copay

33
Q

Out of Pocket doesn’t include…

A

Premiums or excluded care

34
Q

Stop Loss is the…

A

Out of pocket limit

35
Q

ACA Plans must have out of pocket limits for…

A

Essential health benefits

36
Q

Reimbursement Plan

A

Pay based on cost of care received

37
Q

Reimbursement plans typically involve reimbursing the policyholder rather than…

A

Paying the provider directly

38
Q

Reimbursement plans are typically sold by…

A

For-profit insurers

39
Q

Reimbursement plans typically don’t emphasize a…

A

Network for providers

40
Q

Service Plans

A

Subscribers pay premiums for future medical services, not for reimbursement

41
Q

Service plans arrange for care options via a…

A

Network of physicians who either work for or have contracts with them

42
Q

BCBS is typically operated as a…

A

Non-profit service plan

43
Q

Managed Care Plans

A

Plans that attempt to control how care is provided in order to improve efficiency and reduce costs

44
Q

Pre-Authorization Requirements

A

Required before being admitted to facility

45
Q

Concurrent Review

A

Ensure prompt discharge from facility

46
Q

Managed Care Plans’ coverage is typically…

A

Limited or no out-of-network coverage

47
Q

HMO stands for…

A

Health Maintenance Organization

48
Q

HMO: Has what level of managed care?

A

High level

49
Q

HMO: Has a close relationship between…

A

Plan and Physician

50
Q

HMO: Responsible for…

A

Paying and providing care

51
Q

HMO: Providers are paid…

A

Flat annual or monthly fee or per patient, not per service performed

52
Q

Capitation

A

Flat monthly or annual fee

53
Q

HMO: Primary care physician acts as a…

A

Gatekeeper for referrals to specialists

54
Q

HMO: All care must be provided by…

A

In-network providers, other than emergencies

55
Q

HMO: Emphasis on…

A

Preventive care

56
Q

HMO: Premiums are…

A

Low and has limited cost-sharing, emphasis on small copayments

57
Q

PPO stands for…

A

Preferred Provider Organization

58
Q

PPO: Has what level of managed care?

A

Moderate

59
Q

PPO: Contracts with physicians who provide care to subscribers at…

A

Reduced fee-for-service rate

60
Q

PPO: Covers in-network care at what amount? Covers out-of-network at what amount?

A

Higher; Lower

61
Q

PPO: For out-of-network emergency…

A

No reduction in benefits

62
Q

PPO: For specialists…

A

Often no primary care referral necessary

63
Q

POS stands for…

A

Point of Service

64
Q

POS: Like HMO, care is managed by…

A

Primary care physician

65
Q

POS: Like PPO, some coverage for…

A

Out-of-network care, though less coverage

IL Life and Health Insurance (29 decks)

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