Medical Plans Flashcards
Basic Medical Expense Insurance is what?
What’s are the details of this policy?
Medical, hospital and surgical benefits
No Deductible (first dollar coverage)
Low dollar limits
No protection for financially disastrous expenses
Fee for service vs Prepaid plans ?
Receive payment for each service
&
Regularly even if no service provided
Specified Coverage ?
Limit coverage to one illness or one limiting group of coverages
Cancer policies, drug coverage dental
Stand alone or complementary major med exp policy
Comprehensive Care covers what?
Most types of medical expenses
Outpatient services
Hospitalization
Health care services
Preventative, immunization
Major Medical Insurance (Indemnity Plans) serves what purpose ?
Provide protection against catastrophic loss.
Uses deductibles and Coinsurance
Doesn’t respond to small claims
Major Medical expense contracts are characterized by :
High Maximum limits, Blanket coverage, Coinsurance, a Deductible
Another name for Major Medical Plans
Covered or Eligible Expense Plans
Major Medical Insurance Exclusions ?
Cosmetics
Custodial Care
War, suicide, dental vision hearing
Major Medical policy premium vary depending on ?
Deductible,
Coinsurance percentage,
Stop loss amount,
Max amount of benefit
Major Med Ins: if deductible is high ?
If it’s low ?
Lower premium
Higher premium
Coinsurance serves what purpose ? What are the percentages?
Keep costs down by requiring insured payments
90/10 80/20 70/30 50/50
What is a stop loss feature?
Amount insured pays out of pocket in a year.
Once stop loss is reached, insurer covers 100%
The higher the stop loss the lower/higher the premium?
Lower
What is the purpose of the impairment (exclusion) rider?
Eliminate coverage for a specific pre existing condition
Only means of purchasing coverage
No extra cost
Health Maintenance Organizations (HMOs) serve what purpose?
Provide benefits in the form of services
Preventative care
Provide financing and patient care
HMOs are offered to who?
Those living within a specific boundary
Do HMOs have deductibles ?
No, rather copayment
What is meant by HMOs operating on a capitated basis?
HMO receives flat rate attributed to ea member (prepaid) money ready to go
Goals of HMOs?
Reduce costs of health care by
Utilizing preventative care.
Free annual check up
Free low cost immunizations
HMO provides ?
Inpatient hospital care in or out the service area
Basic benefits of HMOs?
Hospital inpatient
Physician
Outpatient medical
Preventive
Urgent care
Emergency care
Diagnostic lab / Out of area
HMO Supplemental service Benefits include ?
Long Term Care
Nursing Services
Home Health Care
Prescription Drugs
Dental care
Vision care
Mental health care, substance abuse
Preferred Provider Organization PPO explained?
Traditional med system
Paid for service
PPOs differ from HMOs how?
Don’t provide care on prepaid basis
Subscribers not required to use doctors on list
Reduced fee
Which is more flexible between In Network & Out of Network providers ?
In network providers are more flexible
Out of network have higher costs
Point of Service is what ?
Combo of HMO & PPO plans
different choose of plan can be made as need arises
Limited Health Insurance does what ?
How is this paid ?
Cover specific accident or sickness limited perils and amounts of coverage
Paid on expense paid basis, indemnity
Accidental Death and Dismemberment (AD&D) explained ?
Ride or separate policy
Usually group life or group health
Benefits in event of loss death or dismemberment
AD&D pays principle or capital sum for accidental death ?
principle
AD&D pays capital sum if what?
Loss of sight or accidental dismemberment
A percentage of the principle sum
AD&D will pay benefits as long as death cause by accident occurs in how many days ?
90 Days
What is hospital indemnity?
Daily, weekly, monthly payments while confined in a hospital.
Hospital fixed rate policy
Based on number of days
What is a Specified Dread Disease?
Specific diseases:
Cancer or heart
Hospital confinement or chemo
Paid scheduled fixed amt
What is a critical illness policy?
Multiple diseases
Heart attack, stroke, renal failure
Lump sum
Min number of days insured must survive after diagnosis
What is a managed care plan?
HMOs PPOs designed to control costs by controlling behavior of participants
What is prospective review ?
Submit claim info to see if procedure is covered ?
Concurrent review is what ?
Insurance company will monitor stay to make sure staying to plan
What does Health Insurance Portability and Accountability Act
HIPPA do ?
Regulates Protection for:
Group health
Individual policies.
HIPPA cannot establish eligibility using which type of factors ?
Health
HIPAA eligibility requirements?
63 days to apply
18 month’s continuous creditable health Group plan most recent
Used COBRA
Not eligible for Medicare or Medicaid
No other health ins
Creditable Coverage means what?
Insured given day for day credit for previous health coverage against application of preexisting condition exclusion period
ACA mandated providers bring what to the public?
Increased preventive Education
And community based health care
The Affordable Care Act, ACA designed to ?
Prevent denials
Pre existing coverage
Keep premium low
Stabilize budget
Set up new competitive private health insurance market
If someone has Medigap (Medicare Supp) they cannot be eligible for ?
Medicaid
To use the marketplace to by insurance
ACA insurers 4 standard ls to base ratios for premium rates ?
Family composition
Age
Geo Rating Area
Tobacco
ACA essential benefits ?
Hospitalization
Maternity
Emergency services
Wellness and preventive services
Chronic disease manage
Metal Levels of ACA coverage ?
- Bronze 60%
- Silver 70%
- Gold 80%
- Platinum
Catastrophic plans offer what as for premiums and deductibles?
Lower premium
Hugh deductible (thousands)
What age are catastrophic plans available?
Adults under 30
Can’t get affordable coverage
Under ACA premium discounts maybe awarded to who ?
Low income individuals regardless of metal level
ACA offers tax deduction or credit for premiums ?
Credit
