Medical Plans and Health Insuring Corporations (CH9) Flashcards
(36 cards)
Capitation
A method of payment from the HIC to the primary care physician (PCP) of members.
Credentialing
The process of screening potential HIC for licensing, quality, ethics, legal compliance, sufficiency of malpractice insurance, etc., before the HIC signs a contract with that provider.
Co-Insurance
In Health Insurance, a provision that the insured and insurance company will share covered losses in agreed proportion. For example, a person may have a $500 deductible and co-insurance (a sharing) of 20% of the first $10,000 of a covered claim.
Community Rating
A method of HIC rate calculation where the rate charged to a group or individual for the HIC coverage is based on the profit or loss experience of the HIC’s entire population.
Deductible
Dollars or percentage of expense that will not be reimbursed by the insurer.
Experience Rating
The loss record of an insured, a class of coverage, or an insurance company.
Fee-for-Service Health Plan
A traditional health care insurance policy in which the insurance company pays fees for the services provided to the insured persons covered by the policy. This type of health insurance offers the most choices of doctors and hospitals.
Also known as Medical Expense Insurance.
Indemnity
Insurance is designed to restore the policy owner to the same financial condition enjoyed prior to a loss. The intent is to cover the amount of the actual loss only; the insured should not profit from a loss situation.
Insured
The party to an insurance agreement to whom, or on behalf of whom, the insurance company agrees to indemnify for losses, provide benefits, or render service. In prepaid hospital service plans, the insured is called the subscriber.
Major Medical Insurance
A type of Health Insurance that provides benefits for most types of medical expe3nses incurred up to a high limit, subject to a deductible. Such contracts may contain a percentage participation clause (sometimes called the co-insurance clause). A major Medical policy pays expenses both in and out of the hospital.
Pre-existing Condition
A condition of health or physical condition that existed before the policy was issued.
Pre-Paid Health Plan
Provides comprehensive health care for members who pay a flat fee for services, regardless of whether outpatient or hospital treatment is needed.
Stop-Loss Amount
The maximum out-of-pocket expense the insured pays in a calendar year, after health insurance. This includes the deductible and the co-insurance portion paid by the insured.
Sara and Jim have a son who is mentally challenged and will be a dependent on them indefinitely. At what age must they provide documentation on their son’s condition in order to continue covering him on their major medical policy?
19
State law has required which provision regarding adoption to be included in all medical insurance policies?
If the adoptive parents have an insurance policy with maternity benefits and the adoptive parents are legally required to pay the maternity expenses of the natural mother and the child is adopted within one year of birth, then the insurance company must pay the natural mother’s maternity expenses.
How many hours of nursery care for a well born baby must be provided by medical insurance plans?
48
When an insurance company bases its payment of benefits on the normal provider’s charges within a certain geographic region, the company is using the
usual, customary, and reasonable charges method.
Bob has a major medical policy with an initial $1,000 deductible and 80/20 co-insurance. If he incurs covered medical expenses of $4,000, he would receive benefits of
$2,400.
In most managed indemnity plans, the insured must obtain prior approval from the insurance company for most elective procedures and some testing procedures which are expensive. This is called
Prospective Review.
While Ken is hospitalized for injuries and physical therapy related to an auto accident, there is consultation between his doctors and the HIC. What is this dimension of consultation called?
concurrent
What best describes a preferred provider organization?
third-party organization providing health care at a reduced fee
Ambulatory services under case management provisions try to monitor:
The cost effectiveness of outpatient services
Bob, who has a family medical plan with a $5,000 deductible, wants to establish a Health Savings Account (HSA). How much of his deductible may Bob put into the account?
100%
Andrea has a major medical policy with a $250 deductible, an 80/20 co-insurance provision, and a $5,000 stop-loss provision. She underwent radical surgery this year, incurring total medical bills of $32,000. Under the provisions of her policy, how much will she have to pay toward these expenses, assuming all are covered?
$5,250
