Medical Expense Plans Flashcards
One of the new ideas that health maintenance organizations (HMOs) brought to health care was providing service on a ______ basis
Prepaid
Traditional fee-for-service health plants refer to customers as _______ because these pains 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 are characterized by:
-low coverage limits
-first-dollar coverage (no-deductible)
Packages together a basic plan and major medical coverage. The basic plan will pay covered expenses with no deductible, up to the basic plan policy limits, then the major medical coverage kicks-in
Supplemental major medical insurance
A stand-alone health plan and benefits are available after the deductible is satisfied. Another feature is the concept of coinsurance, which is th sharing between th insurer and insured of covered expenses that exceed the deductible amount. The sharing ends when the stop-loss limit (max out of pocket limit) is reached
Comprehensive major medical insurance
Under a major medical policy, the insured is no longer required to pay coinsurance when medical expenses exceed this amount
Stop-loss limit
Maximum out of pocket=
The deductible plus the insured’s coinsurance percentage times the stop loss limit
Major medical policy features:
-deductible
-coinsurance
-stop loss
-insured maximum out of pocket
Most common medical expense policy limitations:
-rehabilitation and skilled nursing facility care
-home health care
-hospice care
-ambulance services
-outpatient treatment
-durable medical equipment, such as hospital beds
-infertility treatment
-Maternity care
-mental illness or substance abuse treatment
-organ transplants
-reimbursement for chiropractic or other non-physician services
