Types of NC Health Plans

Question 1

What is Aleatory

Answer 1

An uneven contract

Al does NOT equal Tory

Question 2

Adhesion

Answer 2

The policy is written the way it is, no negotiations

stuck with it… ‘take it, or leave it’

Question 3

Unilateral

Answer 3

The insurer has to stay in the contract, the insured can walk away
(One sided contract)

Question 4

Conditional

Answer 4

Insured has to meet conditions before the insurer has to pay

Question 5

Consideration (all about the money)

Answer 5

The Statements on the application and premium of the insured

Paying the claim for the insurer

Question 6

Agent/Producer

Answer 6

Person employed to sell insurance policies

Question 7

Representation statement

Answer 7

Answering application questions to the best of your knowledge….

 - can lead to misrepresentation (ex: if you fill out an application and you answer 'no' to a health question and you find out later about an illness)

Question 8

Warrantee Statement (Guarantee)

Answer 8

Answering application questions that are guarantees

Question 9

Contract Law (Legal)

Answer 9

CLOC = Consideration, Legal Purpose, Offer & Acceptance, Competent Parties

Question 10

Major Medical Plan

Answer 10

• Protects against the cost of medical expenses

- Covers for catastrophic losses

Question 11

Comprehensive (Major) Medical

Answer 11

Covers all medical expense under one policy

Question 12

Medical Expense Insurnace

Answer 12

Provides financial protection against the cost of medical expenses by reimbursement

Question 13

Family Deductable

Answer 13

Is 2-3 times the individual deductible

Max is 3 times

Question 14

Common Accident Provision

Answer 14

Only the family members in the accident would be covered under this provision

Question 15

PPACA (Patient Protection Affordable Care Act)

Answer 15

• Has a catastrophic plan that can be sold to people under 30
• Does not cover adult dental
• Mandated, increased preventive care, guaranteed issue policies, covers preexisting conditions, community based health care
• Immediately coverage for preexisting conditions
• Covers children up to age 26
• Why buy? Metal Levels (different payment options)

Question 16

Basic Plan (1st-$)

Answer 16

No deductible, first-dollar

Question 17

Basic Insurance

Answer 17

3 Types with very little coverage

• Hospital: In-patient (room & board, medicine, x-rays, etc.)
• Medical: Out-patient, non-surgical (coverage outside of the hospital and surgery)
• Surgical: doctors for surgery

Question 18

Surgical Plan

Answer 18

Covers the surgeon(s) and anesthesiologist

Question 19

Relative Value

Answer 19

Is a way insurers can give their customers the amount of the benefit they are going to cover by using a point system (conversion factor = $ amt each point is worth).

Question 20

Deductable

Answer 20

If you don’t pay it, the insurer won’t pay the claim

Question 21

Co-Insurance (er/ed)

Answer 21

To control overuti/lization

- Sharing phrase (80/20, 70/30) insurer pays the first number, insured pays the second

Question 22

Stop-Loss

Answer 22

Maximum of co-insurance paid in a year by the insured, then insurer will pay all benefits

Question 23

Managed Care (HMO’s & PPO’s)

Answer 23

Preventive care, case management, risk sharing, high quality of care, controlled access to providers

Question 24

HMO’s (Health Maintenance Organizations)

Answer 24

Their purpose is service and financing

• Restrictive geographic location
• Must have PCP (Gatekeeper)
• Closed Panel (work for HMO)
• Open Panel (Dr. is independent)
• Pay co-pay, no deductible, prepaid/capitation
• The insureds are all subscribers
• Covers emergencies and hospitals our of area

Question 25

HMO Provider

Answer 25

To become a HMO provider, you must agree to their terms

Question 26

Gatekeeper

Answer 26

- Controls the cost in an HMO - Is the same as the PCP - Are responsible for your healthcare

Question 27

Open Panel Provider

Answer 27

- Can see any subscriber/insured they wish | - Provider is independent, has own practice

Question 28

Closed Panel Provider

Answer 28

- Employee/Staff of HMO | - Can only see subscriber/insured from the specific HMO

Question 29

HMO vs PPO

Answer 29

- HMO is prepaid/has capitation | - PPO is free for service

Question 30

PPO's (Preferred Provider Organizations)

Answer 30

- Do NOT have a gatekeeper - Sold by private insurers - Able to see any doctor - Pays fee for service - Has lower cost in-network - Tries to funnel insureds into network where cost are known - Part of Managed Care

Question 31

Dread Disease Policies

Answer 31

Is a Limited Policy - "Just Because" (ex. heart disease, cancer, kidney failure) - do not get confused with the medical expense policy that covers specific kinds of illness

Question 32

Preadmission Certificate

Answer 32

Authorization before a service can happen