Unit 26: Medical Expense Insurance Flashcards
Page 255
What are the two broad groups that hospital indemnities are usually classified as?
- Room/board (nursing care, special diets)
- Misc med expenses: xrays, lab fees, meds, med supplies, operating and treatment rooms
What are the two ways the room/board benefit may be paid?
depends on policy:
- indemnity basis
- reimbursement basis
What is another name for an indemnity policy?
“dollar amount” plans
Which is the more common room/board benefit payment?
Reimbursement basis
What is another name for expenses paid on a reimbursement basis?
“expense-incurred” basis
Under reimbursement arrangement, what are the 2 ways a policy will pay?
- actual charges for a semiprivate rm
- a % of actual charges with no specific $ limit, a max # of days will be specified
Page 357
How are benefits for misc med expenses figured?
Limit of benefit is some multiple of the per-day limit for room/broad (i.e. 10 or 20 times for each period of hospitalization)
What is “absolute value” vs. “relative value” when insurers indemnify? pg 357
- ABSOLUTE value: Insurer pays the prevailing value for a certain surgery as indicated in the schedule that accompanies the policy.
- RELATIVE value: Insurer has determined that a certain kind of surgery is only 50% as complex as other surgeries. That is the benefit that will be paid for an unscheduled, less complicated procedure
Page 358
How much will a policy pay for a surgical benefit (and sometimes others) that is not listed by a specific $ amount in a schedule?
Pay based on what is considered Usual, Customary and Reasonable (UCR) in certain geographic areas.
How is is UCR defined? i.e. what criteria do they use to determine what is UCR?
Based on the $ amount physicians in a ceratin area usually chargefor the same/similar procedure. standards for procedures that are USUAL, CUSTOMARY, and REASONABLE
How does using the UCR with non-scheduled plans?
- Allows policies to keep up with inflation
- Avoids policy restructuring every time med costs increase
What is another name for regular medical expense benefits and what does it cover?
“physicians nonsurgical expense”
coverage for nonsurgical services
If physicians visits to hospital are covered, what are the 3 things the benefit usually pays for?
- A specific max number of visits per day
- A specific max $ amt per visit
- A specific max # of days that coverage applies
Page 359
Why is there a waiting period for some policies before they’ll cover maternity benefits?
Usually a 10-month waiting period so people don’t purchase health insurance solely to cover pregnancy/childbirth expenses
For employee groups of 15 or more, what is the law about maternity coverage?
Maternity benefits have to be provided on the same basis as nonmaternity benefits.
Under this size group plan, there is no 10-month waiting period unless that applies to nonmaternity benefits, as well.
How do some policies cover emergency first-aid situations?
(i.e. a med prof may provide first aid services and might bill insured, sometimes without their knowledge)
By including in the policy:
emergency first aid treatment expenses incurred within a very short time after an accident (handwritten - normally 72 hrs)
Length of time is specified in policy.
Page 361
What are some of the common exclusions and limitations in a policy? (only 4 highlighted)
- Pre-existing conditions (defined in the policy and by state)
- self-inflicted injuries
- war or acts of war resulting in death/injury
- injury while committing a felony
What is the benefit/purpose of major medical coverage?
- more complete coverage with fewer gaps
- covers broader range of medical expenses with usually higher individual benefit and policy maximums
How are the major medical policies divided and what do they cover?
Into 2 groups:
- COMPREHENSIVE major medical
(combines traditional/basic coverages and pretty much any other type of med expense) - SUPPLEMENTAL major medical
(coverage starts with traditional/basic policy which pays first, then major med coverage picks up expenses not covered by basic policy)
What are the two types of Comprehensive major medical plans and what do they mean? In relstion to deductibles.
I WOULD LOOK AT CHARTs ON PAGE 363
- WITH First dollar coverage:
As soon as covered medical expenses are incurred, policy starts to pay (deductible still paid by insured, but doesn’t have to be before receiving coverage) … so if poor can pay deductible over time. - WITHOUT first dollar coverage:
Insured pays specified deductible BEFORE policy starts reimbursing
BOTH YOU STILL HAVE TO PAY DEDUCTIBLE ITS JUST A MATTER OF WHEN
What is Coinsurance? (onto page 363)
The insurer AND the insured share any expenses above the deductible amt.
What is the typical split between insurer and insureD in the case of coinsurance?
Insurer always pays bulk of expense – typically 80% vs 20% paid by insured - sometimes 75% vs 25%
What is another name for coinsurance in certain areas?
percentage participation
What is a “stop-loss limit” included in more and more major medical policies?
A dollar amt beyond which the INSURED no longer participates in payment of expenses
After insured’s total coinsurance and deductible payments reaches that amt, INSURER picks up entire cost of remaining expanses up to max of stated benefit.
Page 364
What is included in a basic policy that major medical policy then SUPPLEMENTS? Regarding supplemental major medical benefits
hospital, surgical, medical coverage with an additional policy covering the broader range of medical expenses
In the combination of basic plan and SUPPLEMENTAL major medical coverage, how is the deductible treated?
What happens above deductible limit?
Basic plan will pay covered med expenses with no deductible up to policy limit. Then…
Supplemental major med policy operates exactly like a COMPREHENSIVE policy that provides no other first dollar amounts
Page 365
Nothing highlighted but a chart with lots of handwriting on it. Review it?
Page 367
What happens with a “per-cause” deductible?
The insured pays one deductible for all expenses incurred for the same injury or illness.
ex. you have one injury under your plan and you have to pay a deductible for it, and then, while you’re recovering from that injury, you have another injury that requires medical payout. You will then have to pay deductible on that because it’s per cause.
What happens with an “all-cause” deductible?
Expenses for any number of different, or the same type of illness/accidents, are accumulated to meet the deductible during a singular calendar year.
ex. This means that your deductible does not apply to each individual situation rather, it is cumulative for the whole year so if you have three injuries that meet your deductible amount, then the fourth requires no deductible to be paid, whereas a per cause deductible requires you to meet your deductible limit for every single incident
What is the “carryover provision” usually included in an “all-cause” deductible?
allows expenses incurred during the last 3 months of the calendar year to be carried over into the new year if needed to satisfy the deductible for the next year.
What kind of deductible do policies that cover entire families usually have ?
A family deductible rather than individual deductibles. Operates on all cars deductible may be a little bit higher, but that way each family member doesn’t have to pay the deductible they can reach that deductible cumulatively
Operates on all cars deductible may be a little bit higher, but that way each family member doesn’t have to pay the deductible they can reach that deductible cumulativel
What is the common injury or illness provision regarding deductibles that is favorable to families?
Only 1 deductible must be paid when two or more members of the same family are injured in a common accident or become ill with same sickness.
This would be in relation to a per cars incident for each person will have to pay on their own but now because they have this provision that them getting hurt in the accident This would be in relation to a per cars incident for each person will have to pay on their own but now because they have this provision that them getting hurt in the accident protects them
What are the 2 types of major medical coverage?
comprehensive and supplemental
What is a corridor deductible?
deductible paid and supplemental major medical benefits after the basic plan has been paid that has no deductible, then the plan kicks in that supplement that it does have a deductible
