Health Policies and Plans Flashcards
“Basic” plans predated…
Modern health insurance
Basic plans provided…
First dollar coverage, often with no cost-sharing from the patient
Basic plans had…
Very low benefit limits by modern standards
Hospital Expense Insurance
Covered hospital room and board and other hospital expenses
HEI: Hospital Room and Board
Semi-private room and meals; had a certain per-day limit for specified number of days
HEI: Other Hospital Expenses
Tests, supplies, medicine, transfusions; often capped at multiple of the per-day limit for room and board
HEI: Had no coverage of…
Physician bills or outpatient services, even if care is at the hospital
Surgical Expense Insurance
Covers inpatient or outpatient surgery based on type of procedure
Fee Schedule
Covered amount for specific surgery will be based on preset max already set by insurer for that procedure, regardless of geography
Reasonable and Customary Charges
Covered amount for specific surgery will depend on what most providers typically charge in the area
Patients can be responsible for…
Amounts charged beyond fee schedule/reasonable and customary charges
Surgery Second Opinions
Some non-emergency surgeries aren’t covered without a second opinion
Surgery Second Opinion: Who will pay for second opinion?
Insurer
Surgery Second Opinion: Patient can still get surgery if…
2 surgeons disagree with each other
Physicians Expense Insurance
Pays for physician charges at hospitals, offices, etc.
Physicians Expense Insurance capped at…
Certain dollar amount and/or number of visits
Major Medical Insurance
Pays for hospital, surgical, and physician charges under the same policy
MMI: Has high dollar limits but…
Cost-sharing
MMI: HAs annual out-of-pocket limits per…
Year
Major Medical Insurance was originally bought as…
Supplemental for basic expense policies
MMI: After basic policies were exhausted, consumer…
Paid “corridor deductible” before major medical kicked in
Major Medical Insurance is now bought…
Stand alone, with a deductible at the start
Deductible
Amount of otherwise insured loss that must be paid out of pocket before benefits will kick in
Deductible is typically…
Per year or per cause
Per Cause
Might apply after 30 days of not needing similar care
Per Calendar Year
Might allow for a “carryover provision” for amounts paid in last 3 months of previous year
Family Deductible
Might prevent all members from having to meet their own deductible after a few members have met their own deductible
Coinsurance
Splits the cost of medical bills on a percentage basis
Common coinsurance percentage
80% by insurer, 20% by insured
Coinsurance is applied…
After deductible is met
Copayment
Paid by insured as a flat fee per service; often due at time of service
Out of Pocket Limit
Caps the amount the insured must pay per year in coinsurance fees, deductibles, and sometimes copay
Out of Pocket doesn’t include…
Premiums or excluded care
Stop Loss is the…
Out of pocket limit
ACA Plans must have out of pocket limits for…
Essential health benefits
Reimbursement Plan
Pay based on cost of care received
Reimbursement plans typically involve reimbursing the policyholder rather than…
Paying the provider directly
Reimbursement plans are typically sold by…
For-profit insurers
Reimbursement plans typically don’t emphasize a…
Network for providers
Service Plans
Subscribers pay premiums for future medical services, not for reimbursement
Service plans arrange for care options via a…
Network of physicians who either work for or have contracts with them
BCBS is typically operated as a…
Non-profit service plan
Managed Care Plans
Plans that attempt to control how care is provided in order to improve efficiency and reduce costs
Pre-Authorization Requirements
Required before being admitted to facility
Concurrent Review
Ensure prompt discharge from facility
Managed Care Plans’ coverage is typically…
Limited or no out-of-network coverage
HMO stands for…
Health Maintenance Organization
HMO: Has what level of managed care?
High level
HMO: Has a close relationship between…
Plan and Physician
HMO: Responsible for…
Paying and providing care
HMO: Providers are paid…
Flat annual or monthly fee or per patient, not per service performed
Capitation
Flat monthly or annual fee
HMO: Primary care physician acts as a…
Gatekeeper for referrals to specialists
HMO: All care must be provided by…
In-network providers, other than emergencies
HMO: Emphasis on…
Preventive care
HMO: Premiums are…
Low and has limited cost-sharing, emphasis on small copayments
PPO stands for…
Preferred Provider Organization
PPO: Has what level of managed care?
Moderate
PPO: Contracts with physicians who provide care to subscribers at…
Reduced fee-for-service rate
PPO: Covers in-network care at what amount? Covers out-of-network at what amount?
Higher; Lower
PPO: For out-of-network emergency…
No reduction in benefits
PPO: For specialists…
Often no primary care referral necessary
POS stands for…
Point of Service
POS: Like HMO, care is managed by…
Primary care physician
POS: Like PPO, some coverage for…
Out-of-network care, though less coverage
