38 terms

Chapter 3 (MRT 212)

what is a risk pool
is a group of individual entities such as individual person employers or associations whose healthcare costs are combined for evaluating financial history and experience determing premium or both
what is underwriting
process of identifying and classifying individuals or group risk
when a patients healthcare services are covered under a voluntary healthcare insurance plan who pays the remainder of a healthcare bill after the healthcare insurance company has paid?
The patient pays the remainder of the insurance company pays (guarantor)
The patient and the guarantor are the same person
What are reasons why a healthcare insurance company could reject an applicant for healthcare insurance coverage?
health habits, past medical history, age and income and other factors that affect risk illness or accident.
pays the remainging precentage (e.g. patient pays 20% of insurance pay 80%) The patient & the guarantor is not the same
who is included in a healthcare insurance policy offering dependaent healthcare coverage?
A healthcare plan offering dependent coverage includes benefits for spouses and family memebers of the insured individual.
Which type of policy offers the widest ranging coverage but requires the insured to pay coinsurance until the maxium out-of pocket costs are met?
Comprehensive polices provided coverages for most healthcare services but may have deductibles that must be met before the insured must also pay coinsurance for all covered expenses until the maxium out of pocket cost is reached.
Which of the following is not a type of healthcare policy limitation?
Geographic plan
Under HIPAA any preexisting condition waiting period in a group healthcare plan must be reduced by?
Credit coverage
Describe the types of procedures and services tha typically require prior approval
is typically required for outpatient surgeries; diafnostic, interventional, and therapeutic outpatient procedures; physical; occupation, and speech therapies; mental healh and dependency care; inpatient care, including surgery, home health private nurses, and nursing home and organ transplants.
What is the relation between covered conditions and covered services in private or commerical insurance plans?
Healthcare services related to covered conditions are covered services for which the plan will pay, individual healthcare insurance plans provide fewer covered services at a higher cost than group healthcare insurance plan.
Name at least two of the three benefit terns that means the amount beyound which all covered healthcare services for an insured or dependent are paid 100 percent by the insurance plan?
stop- loss benefit, maximum out of pocket, catastrophic expense limit.
maximum out of pocket cost
specific amount in a time frame such as a year policy holder or dependent are paid at 100 percent by the healtcare insurance plan
Castastrophic expense limit
one year beyond which all covered healtcare services for that policy holder or dependent are paid at 100 percent by the healthcare insurance plan.
covered conditions
health condition illness injury disease or symptom for which the healthcare insurance company will pay.
covered services
specific service for which a healtcare insurance company will pay
Stop loss benefit
specific amount in a certain time frame such as one year beyond which all covered healthcare services for that policyholder or dependent are paid at 100 percent by the healthcare insurance plan
What type of insurance policy provides benefits to (a) a resident requiring nursing home care and services, (b) an insured who becomes blind and (c) a homeowner who requires an eight-month recuoeration after a fall down her basement stairss?
Long term (extended) care policies. Accidental dealth and dismemberment loss policy. Disability income protection policies.
Why can use of a formulary considered a policy limitation?
Because non-formulary product could cost more money.
List at least three typical exclusions found in insurance plan riders.
Experimental or investigational diagnostic and therapeutic procedures. Medically unnecessary diagnostic or therapeutic procedures. Procedures related to preexisting conditions (states) self-inflicted injury, sexually transmitted diseases, was-related injuries, and cosmetic procedures.
use of formulary
is another limitation list of preferred drugs often contain both brand name & generic drugs approved by FDA non formulaty products may be higher
Describe the health insurance plan that covers feeral government employees.
the federal empoyee program covers all enrolled federal government employees across the nation and the globe.
how does blue cross and blue shield notify insured about the extent of payment made on a claim?
The indure receive a explanation of benefits, the notification includes: services provided, amount of bill, amount you do not owe, amount paid by the plan, your balance and the explanation of your balance.
voluntary health insurance plan payments account for about one-fourth of U.S. healthcare expendures
false ( it pays 35%)
Copayments are cost-sharing provisions of polices that required insureds to pay a flat fee to healthcare services provider and suppliers
Individuals having preexisting conditins are financially better off using private healthcare plans than either employer group plans or manged care alternatives
private or commercial healthcare insurance plans and Blue Cross and Blue Shield plans. A small minor category with the voluntary health insurance sector is state healthcare plans for the medically uninsurable.
Types of healthcare insurance include
private or commerical healthcare insurance which can be purchased
Employer based group plans
tend to be more flexible and provide greather benefits at less cost than individual policies
Blue Cross Blue Shield
is a federatin of 39 independent, locally operated plans that collectively form one of the most infuential private groups in the health insurance of last resort fro people who are medically uninsurable.
Healthcare policies are
contracts that formalize the relationship between healthcare insurance companies and the insured individuals or groups
Healthcare insurance policies are
are comprised of sections, such as definitions, eligibility and enrollment, benefits, limitation, exclusions, procedures and appeals processes.
Providers submit claims to
obtain reimbursement
clean claims
receiving timely and accurate reimbursement is dependent upon submitting
mechanisms that explain the amount of the reimbursement are remittance advices
Trends for the future include
increasing healthcare costs for consumers and the continuing evolution of payment methodologies
Value-base insurance design
is the next generation of consumer directed healthcare. These trends will require changing behaviors and ways of thinking for both consumers and providers