Insurance6

Question 1

Medical Plans General Concepts

Answer 1

Fee for service—provider is paid as services are provided—customers called insureds
■ Prepaid—provider is paid a set fee in advance—customers called subscribers/participants
■ Specified coverage—covers only specific services
■ Comprehensive care—covers broad range of services
■ Benefit schedule—pays only a specified amount regardless of the actual charge
■ Usual, Customary, Reasonable (UCR)—pays full charge if reasonable and customary in the same
geographical area
■ Any provider—any provider the insured chooses
■ Limited choice—limited to contracted providers

Question 2

Basic Hospital, Medical, and Surgical Policies

Answer 2

Low coverage amounts
■ No deductibles

Question 3

Major Medical

Answer 3

Broader coverage
–– Supplemental major medical
■ Insured has a basic policy
■ Major medical pays when basic ends
–– Comprehensive major medical
■ Stand alone policy

Question 4

Major Medical Covered Expenses

Answer 4

Hospital inpatient room and board, including intensive and cardiac care
■ Hospital medical and surgical services and supplies
■ Physicians’ diagnostic, medical, and surgical services
■ Other medical practitioners’ services
■ Nursing services, including private-duty service outside a hospital
■ Anesthesia and anesthetist services
■ Outpatient services
■ Ambulance service to and from a hospital
■ First aid and emergency room care
■ X-rays and other diagnostic and laboratory tests
■ Radiological and other types of therapy
■ Prescription drugs administered in the hospital
■ Blood and blood plasma
■ Oxygen and its administration
■ Dental services resulting from injury to natural teeth
■ Convalescent or rehabilitative facility care
■ Home health care services
■ Prosthetic devices when initially purchased
■ Casts, splints, trusses, braces, and crutches
■ Rental of durable equipment such as hospital-type beds and wheelchairs
■ Hospice care—terminal illness care that includes pain relief, symptom management, and
counseling but no curative treatment

Question 5

Major Medical Features

Answer 5

Deductible
–– Paid by insured before ;policy pays
–– Calendar year
■ Coinsurance
–– Insured continues to pay part of the bill after the deductible
–– Insurance company starts paying
–– Usually 80% insurance company and 20% insured
■ Stop Loss
–– Insured no longer shares in the cost when total medical bills above the deductible exceed
this number
■ Insured Maximum Out of Pocket
–– Deductible plus coinsurance

Question 6

Exclusions

Answer 6

Self-inflicted injuries
■ Injury resulting from war or acts of war, whether or not war is officially declared
■ Illness or injury suffered during active military duty
■ Injury resulting from air travel unless the insured is a paying passenger
■ Injury suffered while committing a felony
■ Experimental procedures
■ Care covered by workers’ compensation
■ Care received in a government facility
■ Elective cosmetic surgery (restoration required because of a covered illness or injury is covered)
■ Hearing aids
■ Custodial care