Medical And Dental Plans Flashcards
(42 cards)
Major Medical Ins is considered to be what type of plan
Comprehensive
Purpose of preadmission certification
Eliminate unnecessary treatment thereby lowering premiums
Medical expense policies cover a newborn from when?
The moment of birth
On medical expense ins, what is the most benefit the insurer will pay?
Scheduled benefit limit
Health Care Service Org can be used in place of what term?
Health Maintenance Organization or HMO
HMO primary care doc serves as what between members and health care providers?
Gatekeeper. Primary care doc makes referrals, authorizes treatment, and provides general care
What do Healthcare Service Orgs stress/encourage?
Preventative care
HCSOs pay reimbursements to who?
to providers directly - not to insureds
Group Practice Model
Doc works in an independent group clinic on behalf of an HCSO
HMO primary care docs DONT include who?
Internists
HMO primary care docs include who
family practice, pediatrics, obstetrics and gynecology
Do HMOs cover adult hearing tests as preventative care?
Usually No
HMO services must be provided in network except for
Emergencies
Managed Care does not include what type of plan
Indemnity plans
Managed care includes services provided by who
HMOs, PPOs, and Point of Service POS
Medical expense claims are often paid on what basis?
Fee for service
Major Medical Expense Policies have what deductible (how long)
Comprehensive Calendar Year
What is the difference between concurrent review and pre-certification in utilization management?
Pre-certification is done prior to treatment
What does a stop loss feature do on a major medical policy
Limits the amount of coinsurance the insured has to pay on a large claim
Major medical expense policies are usually written as what, cancellable or noncancellable
Cancellable, the company can cancel at any time as long as it gives advance notice
Medical expense policies have a probationary period, what does it apply to
Applies to pre existing conditions meaning they won’t be covered if it occurs during the probationary period
What does a family deductible do
Limits the total amount the family must pay during the year no matter how many family members get sick
Assignment of benefits on medical expense insurance does what
Allows the insurer to pay benefits directly to the provider
What do you subtract first when calculating how much the company will pay on a claim?
Subtract the deductible first then apply the coinsurance percentage
