Unit 16 Medical Expense Plans Flashcards
Some medical expense policies pay providers for their services according to a ____ schedule. Each type of service is listed with the amount of the payment. If a provider bills more for a service than is shown in the schedule, the patient must pay the difference.
Other medical expense policies pay providers according to what it ____ , and reasonable to charge for that service in that geographic area. As long as the provider’s charge is in line wiht the amount other providers in the area charging for that service, the policy will pay the full amount. However, if the provider’s charge is more than the usual amount, the patient may be billed for the difference.
Benefit Schedule
Usual, Customary, and Reasonable
____(PPO) plans have a panel of physicians and hospitals under contract to provide health care services and generally cover ____% - ____% of the cost. Individuals who choose to use other providers are covered for a smaller percentage of the visits, such as ____%.
Preferred Provider Organization (PPO)
80-100%
60%
Traditional fee-for-service plans, refer to customer as ____ because these plan are issued by insurance companies.
Insureds
Prepaid plans refer to their customers as ____/____, these plans are offered by entities consisting of the providers themselves, such as HMOs.
Subscribers / Participants
Basic hospital, medical, and surgical policies were the original medical expense plans. They had:
- ____
- ____
They had lists of things they covered and if your thing wasn’t on the list it wasn’t covered. If the expense exceeded the scheduled payment limit the insured paid the difference.
Low coverage limits
No deductible (first-dollar coverage)
____ covers a much broader range of medical expenses with fewer gaps and provides higher maximum limits. These more expensive policies are divided into two general groups:
1. ____
2. ____
Major Medical Insurance
1. Supplemental Major Medical Insurance
2. Comprehensive Major Medical Insurance
General Group of Major Medical Insurance #1
____ insurance packages together a basic plan and major medical coverage. The basic plan will pay covered expenses with no deductible, up to basic policy limits, the major medical coverage kicks in. When leaving a basic plan, because the limits are reached, the insured must pay a ____ deductible to begin using the major medical coverage.
Supplemental Major Medical Insurance
Corridor Deductible
General Group of Major Medical Insurance #2
____ insurance is a stand-alone plan and benefits are available after the deductible is satisfied. Another feature is the concept of coinsurance, which is the sharing between the insurer and the insured of covered expenses that exceed the deductible amount. The sharing ends when the ____ limit (max out-of-pocket limit) is reached.
Comprehensive Major Medical Insurance
Stop-Loss Limit
Supplemental and Comprehensive Major Medical Insurance Covered Expenses: (21)
Part 1
- Hospital inpatient room and board, including intensive and cardiac care
- Hospital medical and surgical services and supplies
- Physicians’ diagnostic, medical, and surgical services
- Other medical practitioners’ services
- Nursing services, including private-duty service outside a hospital
- Anesthesia and anesthetist services
- Outpatient services
- Ambulance service to and from a hospital
- First aid and emergency room care
- X-rays and other diagnostic and lab tests
Supplemental and Comprehensive Major Medical Insurance Covered Expenses: (21)
Part 2
- Radiological and other types of therapy
- Prescription drugs administered by the hospital
- Blood and blood plasma
- Oxygen and its administration
- Dental services resulting from injury to natural teeth
- Convalescent or rehab facility care
- Home health care services
- Prosthetic devices when initially purchased
- Casts, splints, trusses, braces, and crutches
- Rental of equipment like hospital beds and wheelchairs
- Hospice care
The deductible requires the insured to pay a certain amount of their medical expenses each ____ before coverage begins.
Calendar Year
Policies that cover entire families have a ____ deductible rather than an individual deductible. For example, the individual deductible is $500, and the family deductible is $1000. A family of six would pay no more than $1000, not $3000 which would apply if each individual paid a $500 deductible
Family Deductible
With supplemental major medical insurance, the deductible kicks in after the basic policy limits are reached. The ____ deductible must be paid to begin using the supplemental plan AND ANOTHER deductible would apply.
For example, Ray has a basic medical policy with a $1000 limit and supplemental major medical insurance with a $500 deductible. Ray exceeds the $1000 medical expense plan limit, pays a corridor deductible and any expense that exceeds $1000 will be picked up by the supplemental major medical policy after its deductible has been satisfied.
Corridor Deductible
____ is a cost-sharing feature that keeps major medical insurance affordable. The insured pays a certain percentage of medical expenses after the deductible has been satisfied. Different coinsurance arrangements are available, the most common is ____, the insurer pays ____% and the insured pays ____% during the time the sharing arrangement applies.
Coinsurance
80-20
80%
20%
Major medical policies often include a ____ limit, the insured is no longer required to pay coinsurance when medical expenses exceed this amount.
If Austin had a stop-loss limit of $5000, he would no longer be required to pay coinsurance after medical expenses totaled $5500. At that point, he would have paid $1000 in coinsurance ($5000 x 20%) plus the $500 deductible.
Stop-Loss Limit
