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
