Medical Expense Insurance Flashcards
Basic medical expense insurance sometimes called “first dollar insurance” does what?
Provides benefits up front without having to satisfy a deductible
The fee charged by a physician or other health professional is called a what?
Usual, customary and reasonable expense
Hospital expense policies are covered when?
While the insured is confined in a hospital
What are the limits on these policies for number of days and deductible limits?
No specific amount
Surgical schedule approach?
Every surgery cal procedure is assigned a dollar amount by the insurer
Usual, customary, and reasonable approach?
Surgical expense is compared to what is deemed reasonable and customary for the geographical part of the country where the surgery was performed.. this is the maximum amount an insurer will consider eligible for reimbursement under a health plan.
Relative value approach?
Instead of a flat dollar amount like the surgical schedule method, a specified set of units is assigned. It will carry a filler per units amount to determine the benifit known as the conversion factor
Major medical expense plans differ from basic medical expense plans how?
They usually carry deductibles, coinsurance requirements and have large benefit maximums
Coverage under major medical expense plans is provided for what?
Both inpatient and outpatient hospital expenses
Drug formulary is what?
The list of prescription drugs covered by a pharmacy benefit
supplementary major medical?
Provides coverage for expense that were not covered by basic policy
Comprehensive major medical?
Combines the features of basic expense coverage and major medical coverage, sold as one policy
Deductible?
The specific dollar amount an individual is required to pay before insurance benefits are paid
Deductibles are used primarily to help control the cost of premiums and reduce over-utilization of medical services.
True
The term “deductible” is use most frequently with major medical insurance policies
True dat nigga
Flat deductible?
A stated dollar amount that applies to a covered loss. Sometimes referee to as an “initial deductible”
Corridor deductible?
Applied after the basic coverage has been exhausted after a major medical policy is supplementing the basic coverage. Ifffffff it contains no deductible
Integrated deductible
Used when a major medical plan is supplementing basic coverages.
Per cause deductible
Insured must pay each deductible for each accident
All cause deductible
Insured only has to meet the deductible once during the benifit period
Carry over provision
Allows insured to defer current health charges to the following years deductible instead of the current years. Also the period normally applies to the expense incurred during the last three months of the plan year
Coinsurance
Sharing of expenses by the insured and the insurer and its purpose is to reduce over utilization of the coverages
Also wth coinsurance…
After the insured pays the deductible the insurance company pays up to 75-80% of the additional expense leaving the rest to the insured, hence the term “coinsurance”
Stop loss provision
Limits the amount of an insureds out of pocket medical expenses
