Types Of Health Policies Flashcards
Medical Expense Insurance is made up of
Basic hospital, surgical, and medical policies and the Major Medical Policies
Basic coverages (hospital, surgical, medical) can be purchased how
Separately or together In a package
First dollar means the same as
No deductible
What does Basic Hospital Expense Coverage cover
Hospital room and board, lab and x-day expenses, medicines, use of operating room and supplies, while the insured is confined in a hospital
Basic Medical Expense Coverage covers what (also refers to as Basic physicians nonsurgical expense coverage)
Provides coverage of nonsurgical services a physician provides. Benefits are limited to visits to patients confined in the hospital.
How is basic medical coverage limited
Usually by number of visits per day, limit per visit, or limit per hospital stay.
Basic medical and also be purchased to cover
Emergency accident benefits, maternity benefits, mental and nervous disorders, hospice care, home health care, outpatient care, and nurses expense.
Basic surgical expense coverage is often written in conjunction with hospital expense policies. This covers
Cost of surgeon services, performed in or out of the hospital. No deductible but coverage is limited
Major medical policies usually provide for
- Comprehensive coverage for hospital expenses ( room and board, and miscellaneous expenses, nursing expenses, physicians services )
- Catastrophic medical expense protection
- Benefits for prolonged injury or illness.
Supplemental major medical policies are used to supplement the coverage payable under a basic medical expense policy. Before the supplemental coverage takes place after basic medical has pays, the supplemental takes effect:
On a first dollar basis( no-deductible) but a corridor deductible must be paid after basic expenses are exhausted and before supplemental picks the the remaining cost.
The Health Maintenance Act of 1973 helped develop Health Maintenance organizations (HMOs). The act forced
Employers with more than 25 employees to offer the HMO as an alternative to their regular health plans.
The main goal of the HMO act was
Reduce the cost of health by utilizing preventative care
HMO’s offer free
Annual check ups and free or low cost immunizations
HMO provide benefits in the form of
Services, rather than reimbursement for services. It provides both financing and patient care
HMOs are organized geographically. That means
If you live within the geographic limitations for an HMO, you are eligible, if not, you are ineligible
HMOs have a limited choice of providers. The purpose of this is
To limit costs by only providing care from physicians that meet their standards, and provide care at a pre negotiated price
HMOs also require copayments. This payment is required to paid for
Each visit
HMOs operate on a capitated basis. This means
The HMO receives a flat amount each month attributed to each member WHETHER YOU SEE A PHYSICIAN OR NOT
HMOs have 4 general characteristics
- Limited Service Area
- Limited Choice of Providers
- Copayments
- Prepaid Basis
Primary Care Physician or gatekeeper is chosen
When a person becomes a member of an HMO.
What kind of care does an HMO provide other than preventative
Inpatient hospital care in or out of the HMOs service area.
Inpatient hospital care of an HMO my be limited for what conditions
- Treatment of mental disorders
- Emotional disorders
- Nervous disorders
Including alcohol or drug rehabilitation of treatment
Can emergency care by an HMO be given to someone outside for the service area?
Yes. Emergency care must be given to a member both in and out of the service care area.
Preferred Provider Organizations (PPOs), rather pay physicians on a salary basis like HMOs
Pay physicians on paid fees for services.