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Ch. 3 Basic of health Insurance
Terms in this set (16)
Describe the history of insurance in the United States.
From the 1960's and until now Health Insurance has changed dramatically. The Franklin Health Assurance Company of Massachusetts began offering insurance for nonfatal injury. Travelers Insurance Company of Hartford started using a similar plan we use today by providing health insurance to injured or ill employees. 1n 1960's private companies sold policies to individuals with hospital, surgical fees, denial insurance disability insurance and physicians' services. Rising health care cost forced the federal government to adopt cost-containment policies for Medicare , Medicaid and TRICARE programs to assist individuals with low incomes that couldn't afford health care. Now insurance plans could be based on Individuals and there personal needs.
State four concepts of a valid insurance contract
1. The person must be mentally competent adult and not under the inflence of drugs or alcohol when signing the computer.
2. The insurance company must value (make an offer (the signed application), and the person must accept the offer (issuance of the policy ), without concealment or misrepresentation of facts on the application.
3. An exchange of value (the first premium, payment) submitted with the application, known as a consideration, must be present.
4. A legal purpose must exist, which is an insurable interest in case of a health insurance policy. This means that the policyholder expects to con of continue in a good health but the insurance policy will provide something of value if accident or illness strikes.
is a legally enforceable agreement or contract
An individual promising to pay for medical service rendered
3. List five health insurance policy renewal provisions :
a. Cancelable -policy grants the insurer the right to cancel the policy any time and for any reason.
b. Optionally renewable - policy, the insurer has the right to refuse to renew the policy on a date (premium due or anniversary date) specified in the contract and may add coverage limitations or increase premium rates.
c. Conditionally renewable -policies grant the insurer a limited right to refuse to renew a health insurance policy at the end of a premium payment period.
d. Guaranted renewable -classification is desirable because the insurer is required to renew the policy until the insured reaches the age specified in the contract.
e. Noncancelable policy-the insurer cannot increase premium rates and must renew the policy until the insured reaches the age specified in the contract.
Insurance reimbursement or payment is also called
Name two general health insurance policy limitations
a. Exclusions -If a person has injuries or illness that is excluded in his or her policy, then there is no insurance coverage for that injury or illness.
b. Preexisting conditions-Many policies do not provide benefits for conditions that existed and were treated before the policy was issued.
A Waiver or raider
is an attachment to a policy that modifies clauses and provisions of the policy by either adding coverage or excluding certain illnesses or debilities that would otherwise be coverages.
treatment is coverage under an individuals health insurance policy is called
The Determining the maximum dollars amount the insurance company will pay for a procedure before it is done is known as
Name three ways an individual may obtain health insurance:
a. Take out insurance through a group plan(contract or policy)
b. Pay the premium on an individual basis,
c. Enroll in a prepaid health plan
contract is any insurance plan by which a group of employees (and their eligible dependents) or other homogeneous group is insured a single policy issued to their employer or leader, which individual certificates given to each insured individual or family unit.
- if a person leaves the employer or organization may continue the same or lesser coverage under an individual policy if the group has a conversation privilege.
is a advantageous to convert to an individual policy because no physical examination is required; therefore a preexisting condition cannot be excluded.
Consolidated Omnibus budget Reconciliation Act of 1985 (COBRA)
Company with 20 or more health insurance coverage be extended to the employee and his or her dependents at group rates for up to 18 months. However the employee must pay for the group policy; this is called a income continuation benefits.
List four methods a physician's practice may use to submit insurance claims to insurance companies.
1. Posting charges and submitting to the insurance payer on the legacy paper CMS (formerly HCFA) 1500 (80-05) claims.
2. Electronic claims transmitted from in -office computers.
3. Contracting with an outside billing service company to prepare and electronically transmit claims on behalf of the health care provider's office.
4. Direct data entry (DDE) into the payer's system. The billing specialist logs into the insurance company's system and keys in the data required to process the claim .
THIS SET IS OFTEN IN FOLDERS WITH...
insurance hand book chapter #11
Chapter 1 - Medical Insurance
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