Medical Plans Flashcards
(93 cards)
Medical expense insurance plans are divided into two classes. What are they?
1.Indemnity policies
2.Managed care plans
This type of policy/plan collects premiums from the insured and the insured pays for medical care. The insurer then reimburses the insured for some or all of the cost of care. The insured can also choose any medical care provider.
Medical expense indemnity policy
This policy/plan collects premiums from the insured and then the insurer pays for covered medical care. Generally the insured must use a medical provider in the network.
Medical expense Managed care
What plan/policy includes health maintenance organizations (HMO’s) and preferred provider organizations (PPO’s)?
Medical expense managed care
Managed care plans combine characteristics of what?
A health care provider and an insurer
Medical expense plans provide either Specified or ___ kind of coverage?
Specified or Comprehensive coverage
This type of coverage addresses a specific form of care:Hospital only, vision only, dental only?
Specified coverage
This kind of coverage addresses a variety of conditions or medical services: routine doctor visits, hospital expenses, surgical care, etc?
Comprehensive coverage
This method of reimbursement is based on the schedule of benefit amount per medical procedure..used today only with “basic plans”
Benefit schedule
This method of reimbursement is based on typical rates in the geographical area where services are provided? Costs in larger urban areas are typically higher than in more rural areas.
Usual, customary, and reasonable (UCR)
True or False: Managed care plans ONLY let members use “in network” providers?
False- used to be that way, and Modern plans still favor providers “in network”, but now they let a member choose out of network, though less coverage may be provided or higher costs is they choose a provider “out of network”
The oldest form of medical expense insurance. Covers a specific form of medical care. There is no deductible or copayment amount-Pays claims on a “first dollar” basis.
Basic medical expense (indemnity) policies
Basic medical expense plans reimburse all covered expenses up to what?
The policy’s maximum amount
What are the 3 types of basic medical expense policies?
1.Hospital expense
2.Surgical expense
3.Physician expense
What does a basic hospital expense policy cover? What does it NOT cover?
Daily hospital room and board, and miscellaneous expenses. Pays maximum per-day benefit for certain amount of days, OR a maximum dollar amount.
Does NOT cover physician services or surgeon fees.
What does basic surgical expense policies cover? What is the reimbursement method?
covers surgeons fees and costs..uses UCR reimbursement method
What does a physician expense policy cover? what is the benefit amount?
Attending physician in hospital or doctor visits,xrays,lab charges…benefit is max dollar amount per visit
Why is the popularity of basic medical expense insurance policies diminishing?
The value of “first dollar coverage” with it’s limited dollar amounts is weakening as medical care becomes more expensive.
What makes a major medical expense plan better suited than basic expense plan for policies covering expensive illnesses or injuries?
Broad coverage and high benefit limits.
Used with comprehensive major medical policies, a flat deductible is what?
The amount the insured pays before the policy pays benefits.
What is the term for when the percentage of medical charges exceeds the deductible, which the insured is responsible for paying?
Coinsurance.
Used only with supplemental major medical policies…what is the term for the amount the insured pays after the basic plan pays benefits and before the supplemental plan pays its benefits?
A Corridor deductible
Deductibles can be either flat or?
Corridor
A feature common to major medical expense policies, that protects the insured by limiting the out-of-pocket- dollar amount he or she must pay annually.
Stop-Loss feature
