S1: Major Medical Flashcards
Major Medical: what was it a response to?
Response to increase in medical costs once was it was clear that covering only hospital/physician was inadequate for policyholders
One distinguishing factor between major medical coverage (MMC) and earlier coverages
MMC first time disparate sources of health care costs, such as hospital, physician, and ancillary, were combined/ aggregated into a common policy
What do regulators require a minimum combination of covered services for a policy to be called major medical?
What does it prevent and prohibit (2)
Prevent insurers from misleading consumers with subpar policies that use the name “major medical”.
Prohibit policies with unexpected holes in the benefit plan that will disadvantage the policyholder.
services covered by a major medical insurance policy (4)
Impatient, Outpatient, Ancillary, Prescription Drugs
Networks
Insurance carriers that insurers have developed or contracted with provider networks
Networks
Provider Networks
Collection of doctors, health care professionals, hospitals, and clinics who agreed to collaborate with insurers by servicing to insureds
Networks
Geographic Concentration and example
For decision to develop network or contract with existing network. Etc bluecross/shield build own network
Networks
Who decides how restrictive network is and how do they do this?
Insurer and they use combination of cost and health care patterns
Networks Challenges with providers:
Consolidation of health care
prevents selection of specific providers when building network
Networks Challenges with providers:
Rural Areas
insurers cannot be as restrictive as fewer health providers
Networks: Carriers with geographically diverse customers: Contract with network for hire
develop by company who invests resources to rent network to insurer
Health Insurance Plan types (2)
Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO)
Health Insurance Plan
Health Maintenance Organization (HMO)
insured has primary care provider, referral for specialist, go through family doctor and no coverage outside network
Health Insurance Plan
Preferred Provider Organization (PPO)
primary care provider not needed, insured can visit provider outside of network
Benefit Calculation
Cost Sharing
amount of cost paid by policyholders
Benefit Calculation
Deductible
and what is HDHP
Amount insured ays before insurance coverage
High Deductible Health Plan
Benefit Calculation:
Provider Discounts
health care provider participates in an insurer’s network, there is cost of services provided.
Benefit Calculation:
Provider Discounts - Billed Charges
calculated using the retail, or undiscounted, price the provider charges for a service
