Unit 16 Medical Expense Plans

Question 1

fee for service

Answer 1

provider is paid as services are provided
customers are called insureds

Question 2

prepaid

Answer 2

provider is paid a set fee in advance
customers are called subscribers/ participants

Question 3

specified coverage

Answer 3

covers only specific services

Question 4

comprehensive care

Answer 4

covers broad range of services

Question 5

benefit schedule

Answer 5

pays only a specified amount regardless of the actual charge

Question 6

usual, customary, reasonable (UCR)

Answer 6

pays the full charge is reasonable and customary in the same geographical area

Question 7

any provider

Answer 7

any provider the insured chooses

Question 8

limited choice

Answer 8

limited to contracted providers

Question 9

basic hospital, medical, and surgical policies

Answer 9

the original medical expense plans
low coverage amounts
no deductibles

Question 10

major medical insurance

Answer 10

broader coverage
fewer gaps
high maximum limits
two types
-supplemental major medical (insured has a basic policy, major medical pays when basic ends. has corridor deductible)
-comprehensive major medical (stand-alone policy. has ded/coins/oop max)

Question 11

major medical features

Answer 11

deductible
-paid by the insured before the policy pays
-calendar year
coinsurance
-insured continues to pay part of the bill after the deductible
-insurance company starts paying
-usually 80/20 split
stop loss
-insured no longer shares in the cost when total medical bills above the deductible exceed this number
insured maximum out of pocket
-deductible plus coinsurance