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
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
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
The Stop Loss proision only applies after the __________ has been paid
_______ ___________ 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)
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 _________
If your policy does cover maternity, _________ is not a preexisting condition
Maximum probationary periods on a new policy may be __ months, on reinstatement it is limited to __ days.
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
______________ Is the sharing of a loss between the insurer and the insured after the deductible has been satisfied.
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
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
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 ________.
A review can be done on a prospective, ___________ or ____________ basis.
_________ care was designed to manage fees chared by providers as well as the appropriateness of treatment
____________ 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
______________ review requires a medical monitor to review treatment previously provided to determine if it was appropriate under the circumstances
___________ is when a provider is paid a set fee per HMO enrolle he services, regardless how much service they require.
___________ 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
_________ 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
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
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
___s are arrangements in which insurers contract with a froup of physicians, hospitals and other "preferred providers" at discounted rates
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 _____
A co-payment is only used by an ___
__________ are mainly used by indemnity plans and PPOs. The higher this is, the lower the premium.
Co-insurance is used with _________ plans and ___s
HMOs are ______ health plans
_______ 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 __ _________
In _____ coverage, the underwriter should determine that individual participation meets the company's guidelines in order to prevent _______ selection
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.
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.
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.
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
An advertisement may not make unfair or incomplete comparisons of policies or benefits or otherwise falsely _________ competitors, their policies, services or business methods
Each insurer shall maintain at its home or principal office a fine containing _____ advertisement disseminated in the last _ years
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
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
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.
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
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 ________
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
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
Basic (scheduled) Plan- This plan reimburses _______ charges up to a maximum amount specified on the schedule for each _________ service. No Deductible or co-insurance
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
Combination Plan: Features of both __________ and non scheduled, usually requires pre-_______________
The _________ coverage available on dental plans may differ from one part of the country to another, based upon difference in costs for procedures
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
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
In an ____ Panel System, doctors (including dentists) provide services to both prepaid dental plan subscribers and to non-members
In an ________ Panel System services are only available to the subscribers of the plan
In prepaid dental plans a co _______ is required rather than co-insurance, although deductibles and other limitations pay apply
Treatment of gum problems is called
Treatment of root canals is called
Treatment of fillings, inlay and crowns and bridgework is called
The use of braces to move teeth is called