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Medical Plans

TN Accident & Health (Medical Plans)

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