Day 7: Medical Expense Plans & Group Disability & Dental Insurance
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Created by:
KelleyStark on April 9, 2012
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102 terms
Terms | Definitions |
|---|---|
 reimbusement | Private commercial insurers controlled the health insurance marketplace, writing ____________ or indemnity plans that offer specified coverage to clients |
| service pre paid | Benefit ________ Plans offer more comprehensive care of an ___ ____ basis, although their custmers may have a more limited choice cof doctors and hospitals |
| subscribers | Custmors of Benefit Service Plans are called _____________ |
| hosptial expense deductible room dollar ambulance | Basic ________ ________ Policies: This is a first-dollar coverage with no _________ that pays for hospital _____ and board only, although some policies will also cover miscellaneous expenses up to a certain ______ amount for items like X-rays, _________ and prescription drugs |
| surgical doctor schedule operation no | Medical ________ Expense Ppolicy: This policy covers surgical services of a _______ performed in the hospital. Policy will contain a _______ of _________ coverage indicating the maximum amount payable for each operation listed. It has __ deductible and is often attached to the hospital expense policy |
| physicians hospital hospital no | Basic _________ fees for non-surgical ________ confinement policy (regular medical expense policy): This contract covers doctors visits at the ________ even though no surgery was performed. It has __ deductible |
| medical expense catastrophic supplement | Major _________ ________ Policies: major medical insurance provides benefits for ___________ injury or sickness. These plans were originally designed to __________ the coverage of a base plan. |
| major deductible pay | Comprehensive _____ Medical: In this plan the first dollars of medical expenses are covered under the basic portion of the plan without a __________ up to a specified limit. The major medical portion of the plan begins to ___ only after the basic portion is exhausted |
| corridor | In a comprehensive major medical plan the deductible is called a ________ deductible because it is moved in between the basic portion and the major medical portion |
| in out sickness accident alcohol | Comprehensive Major medical plans will cover you both __ and ___ of the hospital, including room & board and charges for physicals. Coverage is provided for both _________ and ________. Covered expenses include nursing fees, micellaneous hospital charges and often psychiatric care and treatment for _______ or ____ abuse. |
| blanket benefit limits expensive | Comprehensive Major Medical Plans cover on a _____ basis without specifying dollar limits, during your ______ period. There maybe inside ______ on certain coverage such as treatment for drug abuse or maternity. Due to their excellent covereage, Comprehensive Major Medical Plans are _________ |
| higher lower family accident one | The ______ your deductible, the _____ your premium will be. There may be a ______ deductible instead of a per person deductible, which means once the medical expenses for the entire family exceed a certain amount, the deductible no longer applies. As well as a common ________ deductible, which states that if members of the same family are injured by the same cause only ___ deductible applies |
| coinsurance stop loss | The _____________ Provision, is usually designated to require that the insured pay part of ever Major Medical claim is usually 80/20 but they could be 90/10 or 70/30. On a large claim, your 20% portion could be quite substantial so they also offer a _____ _____ provision. This limits your liability on a particular claim to a maximum amount stated in the contract |
| deductible | The Stop Loss proision only applies after the __________ has been paid |
| Health maintenance | _______ ___________ Organizations (HMOs) stress the preventitive approach to providing pre-paid doctor and hospital care. |
| preventative commercial for profit | The principal objective of an HMO is to reduce medical expenses by stressing ___________ medicine through physical exams and diagnostic procedures. HMOs are sometimes owned & controlled by _________ insurers, but many are independently owned. They can be non-profit but most are ___-______ |
| service insurance live | An HMO must operate within a specified geographical area known as the _______ area. The department of ________ must approve the area and all members of the HMO must ______ in that area |
| practice specilizations open panel salaried | HMOs Models of Operation: 1. Group _________ Model (GPM): Comprises a group of physicians of varying _______________ in one facility. The HMO contracts with the group to provide health services to their members. If the group provides services to members and non members it is called an _____ ______ medical group. Under this plan, physicians are not ________ and treat HMO Subscribers in their own office |
| Staff HMO employees | HMOs Models of Operation: 2. ______ Model: A system that is owned, operated and staffed by the ____. The HMO would own a hospital and the physicians and other professions inside would be _________ of the HMO |
| practice doctor independently | HMOs Models of Operation: 3. Independent ________Association Model (IPA): A network of individually practicing _______who contract with the HMO to provide health care services to its members. IPA physiciations are located throught a geographic area and operate ____________. |
| gatekeeper primary reffered emergency ASAP | HMOs often utilize a _____________ system, under which the member selects a _______ -care physician who in turn provides or authorizes all care. Any referral to a specialist must be __________ by this doctor. In an __________, the member's treatment will be covered, but the member but notifiy the primary phyisican ____. |
| illness physical fee groups | HMO benefits are not limited to treatment resulting from ______ or injury, they also include preventitive measure such as ________ exams. Members pay a set ___, usually monthly, which entitles them to health care. Most HMOs only accept enrollments from clearly designated _______ |
| preferred provider hospitals price preferred 100 co payment 80 | _________ _________ Organizations (PPOs): are a compromise between an HMO and a reimbursement plan. It is made up of various ________ and private physiciations who agree to provide services to the insurers client at a predetermined _____. In return the insurer designateds them as a _________ provider. If an insured seeks treatment from them its covered ___% minus a nominal __ _______. If they go to a non-preferred provider, reimbursement benefits will be reduced to __% |
| Dental group integrated scheduled deductible | ______ Insurance is usually only offered on a _____ basis due to the possibility of adverse selection that exists on individual plans. Dental coverage can be __________ or sold on a non integrated basis. It covers treatment on a non scheduled basis depending on what is usual and customary or a _________ basis for fillings, crowns or braces. Usually has a __________ and co insurance. (cosmetic not usually covered) |
| Association | Third- Party _______________ (TPA): A firm that provides administrative services for employers and other associations having Group insurance policies. |
| self funded administrative | If claim costs are fairly predictible, an employer may considered a ____- ________ health care plan. An insurer may be used for these plans under an "______________ Services Only" |
| state birth optional | Medical Expense Insurance Limitations: _____ Law requries that Medical Expense policies cover a newborn child for congenital birth defects from the moment of _____, coverage for maternity expenses is _________ |
| pregnancy | If your policy does cover maternity, _________ is not a preexisting condition |
| 12 10 | Maximum probationary periods on a new policy may be __ months, on reinstatement it is limited to __ days. |
| individual | Group medical expense policies rarely have a probationary period, it is usually found on __________ policies |
| nursing hearing workers com government hospital cosmetic self | Exclusions from Coverage 1. Custodial care in _________ homes 2. Dental care, unless required due to a covered accident 3. Vision/_______ care 4. Sicness or accident covered by ________ ____ 5. Care in military or __________ hospitals 6. Hearing aids and glasses 7. Well-baby care in a _________ nursery 8. _________ surgery, unless required due to a covered accident 9. War related injury/sickness 10. Intentionally ____- inflicted injury |
| Coinsurance | ______________ Is the sharing of a loss between the insurer and the insured after the deductible has been satisfied. |
| coordination | Most medical expense policies usually contain a ___________ of benefits provision, which states that if you are covered by more than one policy, the primary will pay first and the other will pay excess |
| saving preventative | Cost ______ Services: HMOs reduce medical costs by emphasizing ___________ care. HMOs develop standard guidelines for the kinds of preventative care they wiill cover, some HMOs cover only certain tests under certain conditions |
| second reduced | Utilization Management: This is the requirement that the insured obtain a ______ surgical option before having elective surgery. If the client fails to do this, the coverage may be ________. |
| concurrent retrospective | A review can be done on a prospective, ___________ or ____________ basis. |
| managed | _________ care was designed to manage fees chared by providers as well as the appropriateness of treatment |
| utilization | ____________ management addresses the appropriateness of treatment factor by estabilishing a review process |
| prospective advance 24 | A precertification, or ___________ review, states that the policy requires that a doctor verify, in _______, that hospitalization is necessary, reccomend outpatient treatment is possible or determine that no treatement is necessary. (in emergency cases certification must occur within __ hours of admission or benefits may be reduced) |
| concurrent costs ambulatory outpatient | A ___________ review requires a medical monitor to consult with the doctor in an effort to manage _____ during treatment. Some plans require __________ services to be utilized which encourages insured to take advantage of ________ services in lieu of hospitilaztion |
| retrospective | ______________ review requires a medical monitor to review treatment previously provided to determine if it was appropriate under the circumstances |
| Capitation | ___________ is when a provider is paid a set fee per HMO enrolle he services, regardless how much service they require. |
| negotiated | ___________ fee-for-service, pays a certain percentage of the charges billed by the provider andn the patient pays the balance. The provider is paid a separate fee for each procedure or service performed |
| salaried | _________ Physicians should have no strong incentive to provide more care than needed or less care than needed unless they are invovled in a bouns program that is based on individual performance |
| fee | The HMO could pay a physician group for each procedure based on a ___ schedule, which is a table of customary rates paid to members of the group |
| witholding | HMOs can pay their physicians _________ part of the fee. These discourage physicians from administering unnecessary treatment, since they are sharing the risk with the HMO |
| PPO | ___s are arrangements in which insurers contract with a froup of physicians, hospitals and other "preferred providers" at discounted rates |
| dual | Some providers are ____ purpose, allowing subscribers to choose either an HMO or PPO |
| point of service reduced | HMOs that provide coverage for out-of-network services are called _____ __ ________ plans. Coverage is at a _______ reimbursement rate |
| indemnity fee unlimited cheaper | Managed __________ are essentially traditional insurance plans that have borrowed some of the HMO ideas. Provider reimbursement is on a ___-for-service basis and the insured person is responsible for deductibles and coinsurance. The attraction is the ________ choice of doctors, but these pland are not much _______ than traditional indemnity plans |
| HMO serive state | An ___ can market to employer groups and enroll members only within its _______ area. Traditional insurers, may be licensed to operate in a entire _____ |
| HMO | A co-payment is only used by an ___ |
| deductibles | __________ are mainly used by indemnity plans and PPOs. The higher this is, the lower the premium. |
| indemnity PPO | Co-insurance is used with _________ plans and ___s |
| prepaid | HMOs are ______ health plans |
| Tricare Medicare | _______ is a regionally managed health care for active duty member and their families, retirees and their families and survivors of all uniformed service members not eligible for _______ |
| prime extra standard | Tricare has three choices: 1. Tricare _____- Military Treatment Facilities are the prinipal soruce of health care 2. Tricare _____- Preferred provider option 3. Tricare _______- Is a fee-for-service option (CHAMPUS) |
| deductibles co payments | Tricare Prime coverage for active duty members and their families is provided without any _____________ or __ _________ |
| group adverse | In _____ coverage, the underwriter should determine that individual participation meets the company's guidelines in order to prevent _______ selection |
| master insurance | A group insurance policy is a ______ policy, usually between the employer and the insurer. Each individual covered under the group policy is issued a certificate of ___________. |
| covers claim term individual | The Certificate of Insurance lists what the policy ______ and it explains to the insured things such as how to file a _____, the ____ of insurance and the rights to convert from group coverage to an ___________ policy. |
| lower claims | Group rates are usually _____ than individual. In larger groups, rates are based on past ____ experience, which is known as experience rating |
| employer union insurance | Besides small _________ groups, group disability insurance policies may be issued to associations, including a labor _____ which has been organized for purposes other than obtaining ___________ |
| employer employees costs | Multiple ________ Trusts (METs): Provide insurance to small business owners and their _________. The trust gives small business owners the greater benefits and lower _____ that have only been available to large companies. |
| industry | A trust can be an _____ trust formed for employers in the same industry. |
| producers administrators sponsors | METs are formed by insurers, ________, brokers or third party _____________ who are called _________. The sponsor develops the plan, sets the underwriting rules and administers the plan |
| welfare funded 2 federal state authority | Recently employers have formed Multiple Employer ______ Arrangements as an alternative to group insurance to provide self-________ heath care to employees of _ or more large employers. Since some claim welfare benefits, it is regulated under _______ law instead of _____ insurance laws. However you need to obtain a certificate of _______ from the state in order to transact business |
| reserves claims reserves | Due to past problems with unregulated MEWAs, many state regulators fear that they lack financial ________ necessary to pay future _____. So growth has slowed due to increased requirements concerning legal ________. |
| debtor depositor creditor | Many groups are now written to insure customers such as _______ groups, ___________ groups and credit card holder groups. Where the _________ is both the policyholder and the beneficiary. |
| cure | Any offer in an advertisement for free inspection of a policy or an offer of a premium refund is not a ____ for misleading or deceptive statements in advertisements |
| disparage | An advertisement may not make unfair or incomplete comparisons of policies or benefits or otherwise falsely _________ competitors, their policies, services or business methods |
| every 3 | Each insurer shall maintain at its home or principal office a fine containing _____ advertisement disseminated in the last _ years |
| state certificates | The ____ in which a group insurance contract is delivered to the policyholder is generally held to have regulatory jurisdiction over all ___________ issued under the contract |
| probationary portable | It is now not uncommon to see _____________ periods for pre-existing conditions on group contracts, although under the new federal HIPPA rules, coverage for individuals moving from one group is __________ meaning not new probationary period can apply. |
| 6 12 pregnancy 30 | Under HIPPA, The look back period for pre-existing conditions is _ months and a pre-existing condition becomes covered after __ months. __________ cannot be considered a pre-existing conditions and newborns & adopted children may be enrolled within __ days without any pre-existing condition limitations |
| without employees fraud premiums | Under HIPPA, all small employer groups (2-50 emp) must be accepted for insurance _________ regard to the health status of the _________. They must get renewed except in the case of ______ or nonpayment of __________ |
| employer full exam deductible taxable | The group policyholder (the _________) sets the eligibility standards since its their policy. Normally ____ time employees are eligible, as well as dependents (may require an additional premium) A physical ____ is not required. Premiums paid by the employer are tax __________ but benefits paid to employees are not _________ |
| benefits primary longest | Coordination of ________ Provision: this determines which policy is _________ and which is excess. If the rule does not clarify, then the benefits of the plan that covered the claimant the _________ is primary |
| insurance pending cover probationary | Change of _________ Companies: In cases in which one group insurance contract replaces a plan of another carrier, the prior carrier shall remain liable for all ________ claims. The new carrier must also continue to ______ each person who was covered under the prior plan, with no new _____________ period |
| 31 | Events that Terminate Coverage: When a covered individual terminates employment or is put in a different position that isn't eligible, you can convert within __ days. |
| benefits disabled | Extension of _________: When a group policy is discontinued the policy must provide for a reasonable extension of benefits to any covered person who is totally _________ at the time the policy is terminated |
| omnibus federal 20 employees 18 | Continuation of Coverage: The Consolidated ________ Budget Reconciliation Act is a _______ law that required employers with __ or more employees to provide for continuation of benefits under the employer's group insurance plan for former ___________ and their families for at least __ months |
| qualifying 60 45 | Upon the occurrence of a "___________ event" the employee or family member must notify the group insurer or plan administrator, who must provide up to __ days for coverage election under COBRA. After coverage election, employees or family members have __ days to pay the premium |
| 2 guaranteed | HIPAA requires that every insurer who offers individual heal insurance make available at least _ plans on an _________ issue basis for certain "eligible" individuals |
| group 18 63 COBRA Medicaid | Under HIPAA an individual is eligible if: 1. They most recent health coverage was _____ insurance (or a church/gov plan) 2. They have at least __ months of prior "creditable" coverage 3. No lapse greater than __ days 4. They elected and exhausted _______ 5. They are not eligible for covered under Medicare or ________ |
| group convertible | Dental insurance is usually offered only under _____ plans. and is not _________ to an individual policy upon termination |
| expense medicare integrated optional | Dental is not covered by most medical _________ policies or by _________. Dental may be written as non-_____________ (stand-alone) group policy or can be included as an __________ coverage on group medical expense policy |
| major deductible | If written as part of a group ______ medical policy, the dental and the medical coverage may be integrated and the _________ amount can be met by either dental or medical expenses |
| dental covered | Indemnity Dental: Basic (scheduled) Plan- This plan reimburses _______ charges up to a maximum amount specified on the schedule for each _________ service. No Deductible or co-insurance |
| deductible preventative | Indemnity Dental: Comprehensive (non scheduled) plan- Benefits are subject to calendar year ____________ and coinsurance, although the deductible does not apply to _____________ care such as cleaning or exams |
| scheduled authorization | Indemnity Dental: Combination Plan: Features of both __________ and non scheduled, usually requires pre-_______________ |
| maximum | The _________ coverage available on dental plans may differ from one part of the country to another, based upon difference in costs for procedures |
| 2 teeth | Limitations may apply to the number of preventative care visits allowed in a 12 month period... usually _. There is no limit on the number of ______ needing treatment |
| cosmetic | There is no coverage for _________ dentistry or non-standard procedures. |
| HMOs cost type | Prepaid dental plans operate in the same manner as ___s. They offer services based on capitation, where the dental plan assumes the full risk for the _____ of services without regard to _____ or frequency |
| open | In an ____ Panel System, doctors (including dentists) provide services to both prepaid dental plan subscribers and to non-members |
| closed | In an ________ Panel System services are only available to the subscribers of the plan |
| payment | In prepaid dental plans a co _______ is required rather than co-insurance, although deductibles and other limitations pay apply |
| periodontics | Treatment of gum problems is called |
| endodontics | Treatment of root canals is called |
| prosthodontics | Treatment of fillings, inlay and crowns and bridgework is called |
| orthodontics | The use of braces to move teeth is called |
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