Medical Plans Flashcards
Medical expense insurance plans are divided into two classes. What are they?
1.Indemnity policies
2.Managed care plans
This type of policy/plan collects premiums from the insured and the insured pays for medical care. The insurer then reimburses the insured for some or all of the cost of care. The insured can also choose any medical care provider.
Medical expense indemnity policy
This policy/plan collects premiums from the insured and then the insurer pays for covered medical care. Generally the insured must use a medical provider in the network.
Medical expense Managed care
What plan/policy includes health maintenance organizations (HMO’s) and preferred provider organizations (PPO’s)?
Medical expense managed care
Managed care plans combine characteristics of what?
A health care provider and an insurer
Medical expense plans provide either Specified or ___ kind of coverage?
Specified or Comprehensive coverage
This type of coverage addresses a specific form of care:Hospital only, vision only, dental only?
Specified coverage
This kind of coverage addresses a variety of conditions or medical services: routine doctor visits, hospital expenses, surgical care, etc?
Comprehensive coverage
This method of reimbursement is based on the schedule of benefit amount per medical procedure..used today only with “basic plans”
Benefit schedule
This method of reimbursement is based on typical rates in the geographical area where services are provided? Costs in larger urban areas are typically higher than in more rural areas.
Usual, customary, and reasonable (UCR)
True or False: Managed care plans ONLY let members use “in network” providers?
False- used to be that way, and Modern plans still favor providers “in network”, but now they let a member choose out of network, though less coverage may be provided or higher costs is they choose a provider “out of network”
The oldest form of medical expense insurance. Covers a specific form of medical care. There is no deductible or copayment amount-Pays claims on a “first dollar” basis.
Basic medical expense (indemnity) policies
Basic medical expense plans reimburse all covered expenses up to what?
The policy’s maximum amount
What are the 3 types of basic medical expense policies?
1.Hospital expense
2.Surgical expense
3.Physician expense
What does a basic hospital expense policy cover? What does it NOT cover?
Daily hospital room and board, and miscellaneous expenses. Pays maximum per-day benefit for certain amount of days, OR a maximum dollar amount.
Does NOT cover physician services or surgeon fees.
What does basic surgical expense policies cover? What is the reimbursement method?
covers surgeons fees and costs..uses UCR reimbursement method
What does a physician expense policy cover? what is the benefit amount?
Attending physician in hospital or doctor visits,xrays,lab charges…benefit is max dollar amount per visit
Why is the popularity of basic medical expense insurance policies diminishing?
The value of “first dollar coverage” with it’s limited dollar amounts is weakening as medical care becomes more expensive.
What makes a major medical expense plan better suited than basic expense plan for policies covering expensive illnesses or injuries?
Broad coverage and high benefit limits.
Used with comprehensive major medical policies, a flat deductible is what?
The amount the insured pays before the policy pays benefits.
What is the term for when the percentage of medical charges exceeds the deductible, which the insured is responsible for paying?
Coinsurance.
Used only with supplemental major medical policies…what is the term for the amount the insured pays after the basic plan pays benefits and before the supplemental plan pays its benefits?
A Corridor deductible
Deductibles can be either flat or?
Corridor
A feature common to major medical expense policies, that protects the insured by limiting the out-of-pocket- dollar amount he or she must pay annually.
Stop-Loss feature
What is the difference between coinsurance and copayment?
Coinsurance is with major medical insurance. It is a percentage of total charges that the insured pays.
A copayment is with managed care plans. Its a flat dollar amount that the member pays per medical visit.
A HMO delivers health care services on a prepaid basis, funded by ?
funded by members premiums
Do HMO’s require a copay?
yes
HMO physicians are HMO employees; PPO physicians are?
PPO physicians are contractors to the PPO
A PCP (primary care physician) is required with which plan? HMO or PPO?
HMO
PPO does not require a PCP
Which plan is easier to go out of network?
PPO
What plan combines characteristics of an HMO and a PPO?
A POS plan
The POS plan is the HMO industry’s response to member’ desire for what?
Desire to select their health care providers
Whats the difference between a blue cross plan and a blue shield plan?
Blue cross-hospital coverage
Blue shield- medical and surgical coverage
What plans established the use of risk pools and the practice of community rating to set premiums. Under a community rating an entire insured group in given area is charged the same rate?
BC/BS plans
Why do basic medical insurance policies typically have no deductible or coinsurance requirements?
B/C “first dollar” coverage reimburses 100% of medical expenses up to the stated policy limit.
What is the difference between a deductible and a coinsurance requirement?
The deductible is upfront and paid out of pocket before benefits are paid.
Coinsurance is a percentage of medical charges that exceeds the deductible, which the insured is responsible for paying.
Managed care plans- what are the 3 types?
HMO
PPO
POS
