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Medical Plans
TN Accident & Health (Medical Plans)
| Term | Definition |
|---|---|
| Fee-For-Service | what approach to claims payments do medical expense indemnity policies use? |
| Prepaid Basis | Managed care plans (such as HMO's and PPO's) operate on a... |
| Insureds | Those who are covered under a traditional indemnity policy are called.... |
| Members | People covered under a managed care plan are called... (Alternately called subscribers or participants) |
| Hospital Expense Insurance, Surgical Expense Insurance, Physician Expense Insurance | What are the 3 general types of basic medical policies? |
| Basic Hospital Expense Policy | Coverage of drugs, x-ray's, lab fees, dressings, and use of the operating room and supplies...... |
| Basic Surgical Expense Policy | Coverage for fees pertaining to an assistant surgeon, anesthesiologist, or even the operating room (if it is not covered as a misc. hospital item).... |
| Basic Physician Expense Policy | Coverage of routine doctor's visits, charges for diagnostic x-rays, and laboratory charges... |
| Major Medical Insurance Policy | Indemnity plans, issued by insurance companies, that pay covered medical expenses far beyond what a basic plan will pay for.... |
| LOW | A high deductible avoids duplicate coverage and helps to keep premiums..... |
| Coinsurance | Has a PERCENTAGE amount for the deductible |
| Copay | Has a FLAT (stated) amount for a deductible |
| Carryover Credit | Eligible health care expenses incurred in the last 3 months of a calendar year can generally be "carried over" and applied toward the deductible requirement of the following calendar year. Applied whether or not the current year deductible has been met. |
| Stop-Loss | Protects the insured by limiting the total out-of-pocket dollar amount they must pay.Once an insured's total deductibles and co-payments equal the stop-loss limit, the policy will pay 100% of all other covered costs for that year. |
| Pre-existing Condition | An illness or medical condition that existed before the policy's effective date. |
| Health Maintenance Organization | HMO |
| HMO | A corporation that delivers health care services on a prepaid basis, financed by members' premiums. Typically operate within specified geographic areas, known as "service areas". Regulated by the states in which they operate. |
| Capitation | An arrangement that pays the HMO provider a set amount for each enrolled person assigned to it, per period of time, whether or not that person seeks care. |
| Closed Panel | An HMO that does not provide services or coverage outside its network is known as.... |
| Preferred Provider Organization | PPO |
| Health Savings Account | HSA |
| Health Savings Account (HSA) | An individual account into which owners make tax-deductible contributions. |
| NO | To qualify for an HSA can the individual be enrolled in Medicare? |
| NO | To qualify for an HSA can the individual be claimed as a dependent by someone else? |
| YES | Are group HSA's portable? If a person changes jobs can it go with the person? |
| Flexible Spending Account | FSA |
| Flexible Spending Account (FSA) | Funded solely by EMPLOYEE contributions before taxes |
| Health Reimbursement Account | HSA |
| Health Reimbursement Account (HRA) | Funded solely by EMPLOYER contributions, which are excluded from employees' gross income. |
| Consumer Driven Health Plans (CDHPs) | Health benefit plans that combine several mechanisms by which consumers choose health care providers and manage health care expenses |
| Accidental Death & Dismemberment (AD&D) | Pays a lump sum of money in the event of the insured's accidental death or dismemberment |
| Accidental Means | AD&D policies that pay on an ____________ basis require that both the cause and the result of an accident arise by chance |
| Accidental Results | AD&D policies that use the ___________ definition require only that the death or injury must be accidental. The cause of the accident is not a factor |
| Principal Sum | The benefit payable from an AD&D policy for accidental DEATH is known as the... (The largest benefit that can be paid from the policy) |
| Capital Sum | The benefit payable from an AD&D policy in the event of accidental DISMEMBERMENT is called the... |
| Contingent Beneficiary | Second in line to receive the death benefit, incase the primary beneficiary is no longer available. |
| Credit Disability Insurance | Covers the risk of a loan customer becoming disabled (and unable to pay off the loan) and pays a monthly benefit equal to the loan payment amount. |
| Blanket Health Insurance | An accident-only policy issued to an organization to protect a group of individuals engaged in a specific |
| 3 | Most indemnity plans group their covered treatment and benefits into _____ classes. |
| Category 1 | Dental treatment includes diagnostic and preventive care, such as routine exams and cleanings. This level of treatment may be covered at 100%. |
| Category 2 | Dental treatment includes basic procedures such as fillings, extractions, and periodontal treatment. This level may be covered at 70 or 80%. The insured must pay the balance. |
| Category 3 | Dental treatment is for major services and treatment, such as oral surgery, and is usually reimbursed at a lower rate, such as 50%. Some dental plans impose a waiting period before _______ treatment is covered. |
| Prepaid Dental Plan | This type of plan provides dental insurance services that have been effectively paid in advance by the plan sponsor, which is typically an employer. |
| DHMOs | Pre-paid dental plans are sometimes called..... |
Created by:
Tiphanie_Dyme
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