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33 Cards in this Set
- Front
- Back
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Basic Medical Expense Insurance |
-provides first dollar coverage with no deductible provision of expense for hospitalization, surgical, and doctor's service -most cos other than BCBS provide reasonable and customary payments for care provided. dollar limits may apply. -can provide benefits per day ($150) much less than what hospital charges, premiums higher for larger amts -periods usually 60, 90 or 120 days, higher premiums for longer coverage |
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Medical Insurance Policy |
-historically only provided coverage when insured was hospitalized but most cover outpatient service now. -BCBS organizations pay for service directly to insurance provider after bills submitted by hospital or doctor -other ins cos pay insured and allow insured to assign benefits to the provider |
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First Dollar coverage |
-no deduction provisions, insurer pays covered losses from first dollar onward |
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Surgical contracts |
-provide coverage for cost of surgical procedures -some specify max amt for specific group of procedures -stated amt is the most insurer will pay for surgical procedure -if patient needs 2 procedures, the most expensive one will determine payment |
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Surgical Schedules |
-pays max dollar amt for most difficult procedure and provides a list of other procedures and their reimbursement rates -modern contract with reasonable and customary basis, no schedule is provided, insurer will reimburse based on average price in that geographical area |
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Major Medical Insurance |
Provides coverage for potentially large medical expense rather than paying for first dollar loss. Valuable family protection but can be expensive. 3 Characteristics: -Deductible Provision -Participation Provision -High Limit of Liability |
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Deductible Provision |
-insured is required to pay portion of medical bills to a substantial deductible. Lowers cost for insurer since not all first dollars of coverage are paid -where procedure is expensive, insured may avoid overuse due to having to pay for deductible. some policies apply deductible to each illness and accident, but has an annual limit -can be thought of as risk retention for insured. Higher deductible, lower the premiums and vice versa. |
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Participation Provision |
-insurer agrees to pay for only a percentage of the bill, insured pays the difference. This sharing of cost is called participation provision. -typically, insurer pays 75-80% while insured pays 20-25% -this coinsurance is another form of insured's risk retention -the more the insured shares, the lower the premium. The less shared, the higher the premium. |
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High Limit of Liability |
-major medical insurance plans have high limits of liability, $50K, $100K or even larger. common limit today is $1M Ex: $18K med exp, $500 deductible, 80% participation provision, insured would recover $14K |
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Medicare |
-insurance for ppl 65 and older, under 65 w/ certain disabilities, and any age with end renal disease (permanent kidney disease) requiring dialysis / transplant. -cost of medicare depends on plan, coverage, or services used -2 ways to get coverage: original Medicare Plan or Medicare Advantage plan HMO/PPO which is called part C. -Part C combines A (hospital ins) w/ B (medical ins. Most C covers prescription drugs. If not, D(prescription drug ins) can be purchased. |
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Medicare cont'd |
-orig medicare plan provides coverage for A & options for B, D, &Medigap (medicare supplement ins) -most ppl qualify for A if they/ spouse have enough work credit, if not, A can be purchased but will be required to purchase B as well. |
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Medicare Part A |
-covers inpatient care in hospitals including critical access hospital and skilled nursing facilities but not custodial or LT care. -if you meet certain conditions, may cover hospice and home health care as well |
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Medicare Part B |
-helps pays for expense such as dr visits, outpatient care, and other med services Part A doesn't cover. -pays for med services &items that are medically necessary & some preventative services. -most ppl pay standard monthly premium for Part B. As of Jan 1, 2007, premium is based on modified adjusted gross income once annual income exceeds certain amt. |
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Medicare Part D |
-Prescription drug coverage, available through private cos that work with Medicare. -there are different types of plans. Once enrolled, changes can be made from Nov. 15-Dec 31 each year. -premium paid monthly and varies on plan -if you choose to not enroll when eligible, you may have to pay a penalty when you choose to join later. -copayment, coinsurance, and sometimes, an annual deductible must be paid. -prescriptions filled with pharmacies working with medicare |
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Medicare Supplement Insurance |
-known as Medigap Ins, designed to supplement benefits provided under Medicare. -covers med deductible, add'l exp when medicare coverage ends & diff if any, b/t reasonable payment provided by medicare for dr's services & amt actually charged by dr. -premiums based on insurer's age at time of policy issued & amt of coverage provided. -typically do not cover intermediate or LT custodial care |
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Medicare Supplement Insurance Cont'd |
-National Assoc of Insurance Commissioner (NAIC) developed 10 standardized medigap plans each covering core group of min benefits. $25K fine imposed for insurers not meeting the below standards: -Open Enrollment -Preexisting Conditions -Duplicate Coverages -Loss Ratios -Guaranteed Renewable |
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Open Enrollment |
–Insurers must accept individuals age 65+ who buy Medigap policies w/i 6 mos of enrolling in Medicare, regardless of their health status, claims experience, or medical condition. |
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Preexisting Conditions |
–Insurers can exclude benefits for conditions diagnosed 6 mos before the policy was issued. |
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Duplicate Coverages |
–Insureres cannot sell a Medigap policy to a person who already has a Medigap policy unless it is a replacement policy. |
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Loss Ratios |
–Medigap policies must return in benefits at least 60 %of premium earned on individually purchased Medigap policies, &at least 75 %of the earned premium on group policies. |
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Guaranteed Renewable |
–Insurers cannot cancel or refuse to renew Medigap policies solely b/c of the insured's health condition. Policies can be cancelled only for nonpayment of premiums or material misrepresentation. |
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Drug Discount Card |
-over 30 Medicare Drug discount card programs to choose from-seniors can only have 1 medicare drug discount card and also have private drug discount cards-must carefully research alternatives |
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Patient's Share |
-patient's share of medicare cost is subject to change yearly -for hospital stays 1-60 days, one time deductible of $1156 -for stays 61-90 days, $289 / day -beyond 90 days, $578 for each day -60-day reserve can be used once in his /her lifetime. -copayment apply to short-term stays in nursing home and certain charges by dr or other service providers -medigap is necessary for majority of ppl |
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Coordination of benefits |
-may not pay or only pays a portion of benefits, if another policy is available to cover loss -this clause prevents insured from collecting more than needed to provide indemnity -determines order in which insurers are responsible in cases of multiple policies -some hospitalizations can be covered by automobile med ins, worker's comp, group med ins, & individually purchased coverage, clause provide guidelines for each insurer's share of what's to be covered. -some clause may determine who pays primary or excess coverage |
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Affordable Care Act |
-study latest info before exam |
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Blue Cross Blue Shield |
-Life ins and BCBS are traditional providers of individual health ins. Offer basic health ins coverage covering first dollar, no deductible but higher premium cost. -pays for benefits directly to participating hospital or dr after bills are submitted by insurer. -coverage depends on #of days in hospital ranging from 70-365 in semi-private rooms and almost all other charges while hospitalized ie labs, xrays, anesthesia, drugs. -BC pays hospital for each day patient is hospitalized based on prenegotiated terms -also pays for surgical procedures and other dr. charges. If there is a diff, patient covers the rest. |
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Health maintenance organizations (HMOs) |
-operate in limited geographic areas, provide broad healthcare coverage for a set fee called capitation payment -employer pays fixed periodic premium in advance to cover medical care services for each participant in the HMO plan. -typically cover dr charges, hospital costs, surgery, X-ray films, &emergency care. -capitation payment does not change w/ usage, but small fee applied to each physician visit or prescription to discourage over-utilization. -b/c of set fee, HMO has a profit incentive to keep members healthy by providing reg physical exams. Private insurers or BCBS generally don't cover preventive physical exam. |
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Health Maintenance Act of 1973 |
-require certain employers to offer HMO in addition to their health ins -600 HMOs cover about 36 million members -younger ppl usually opt for HMO due to preventative care and less amt of paperwork -2 forms of HMOs: Individual practice HMO &Group practice HMO. |
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Individual & Group practice HMOs |
-individual practice HMO contracts w/specific physicians &hospitals. These doctors and hospitals may provide service to the public in addition to members of other HMOs. Participants in this HMOs can choose a dr from among those participating in the plan. Dr charges HMO a fee for each patient seen. -group practice HMO has a limited #of medical providers that a member may use. These doctors and medical professionals often work exclusively for the HMO. |
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Preferred provider organizations (PPOs) |
-usually an assoc of cooperating dr & hospitals, agree to provide employers w/health care services for their employees at discount prices. |
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3 ways PPOs differ from HMOs |
1. employer’s cost w/PPOs is determined by use. Fee is charged for each use, but fee is lower than provider’s usual charge for service provided. 2. covered employees do not have to use personnel or facilities of PPO. If employees use non-PPO providers, however, the employees pay higher costs. Ex, physicians may agree to charge PPO members less than their customary fee for a particular service. Employer’s health care plan may provide reimbursement for 80% of the cost if a PPO provider is used, and only 60 &if employee uses a non-PPO physician. 3. PPO arrangement may not provide coverage for annual physical exams as HMOs do. |
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Patient’s Bill of Rights in 1973, revised in 1992 |
-supports a patient’s right to effective health care in hospitals and in health care institutions. |
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HIPAA |
-significant b/c min fed standards were imposed for all plans nationally, including self insured plans. Two important aspects of HIPAA: -limited exclusion for pre-existing condition(s) for no more than 12 months. A pre-existing condition is one that manifested itself w/i 6 mos prior to enrollment in a group plan. -in the individual market, it made policies guaranteed renewable. |
