1. Under Basic Hospital Expense Policies, there are usually high deductibles. True or False?
    False. There are usually no deductibles on this policy however there is a limit per day with limited number of days. Also, it pays for room and board only.
  2. A medical policy that specifically covers Surgical Services of a physician in a hospital is called?
    Medical Surgical Expense Policy.
  3. Give two other names for the Basic Physicians Fees Policy
    • 1. Regular Medical Expense Policy.
    • 2. Non Surgical Hospital Confinement Policy
  4. Basic Hospital Expense Policies pay for Emergency Treatment and Nursing expenses. True or False?
    False. This is paid by a Basic Physicians Fees Policy.
  5. A Non Surgical Hospital Confinement Policy contains a limited deductible. True or False?
    False. There is no deductible on this policy.
  6. What is a Base Policy?
    One of any of these: Basic Hospital Expense Policies,Regular Medical Expense Policy,Non Surgical Hospital Confinement Policy
  7. Which medical policy is specifically designed for catastrophic injury or sickness?
    Major Medical Expense Policy.
  8. Calculate the benefits for a Major Medical Expense policy for a claim of $2,100 if the deductible is $100 and the coinsurance is 80/20.
    • You would pay $100 plus 20% of the $2,000 remaining or $500.
    • The company would pay $1,600 or 80% of the $2,000.
  9. If not sold as a part of a Base Plan, Major Medical Expense policies have lower premiums due to higher deductibles. True or False?
    True. It was designed to supplement a Base Plan but can be purchased alone with higher deductibles.
  10. What is Co Insurance?
    The sharing of the loss between insurer and insured after the deductible has been satisfied.
  11. What is a Stop Loss when calculating benefit payments?
    Stop Loss is an amount specified in the medical policy that limits the amount that an insured has to pay for a benefit. It is an additional provision which protects the insured from catastrophic loss payments that are due from co insurance payments.
  12. What is the definition of deductible?
    It is the amount the insurer must pay from the total medical expense before any co insurance takes place.
  13. If a Basic Medical Expense policy pays out $1,000 of a $2,000 bill, the remaining $1,000 goes into the Corridor (providing the insurer has Comprehensive Medical Coverage with 80/20 co insurance) how much will the insured have to pay if the Comp deductible is $100?
    $280. $1,000 in Corridor less the deducible = $900 less 80% covered = $780. Subtract that from $900 = $180 + deductible = $280
  14. What kind of policy has a Corridor?
    Comprehensive Major Medical
  15. Comprehensive Major Medical does not cover out of hospital expenses. T or F?
    False. It covers all medical expenses in or out of hospital.
  16. What is the best type of medical insurance policy?
    Comprehensive Major Medical. Covers everything. Also most expensive.
  17. What is a "Blanket Basis"?
    A Major Medical coverage that has no specific individual dollar limits. Your Major Medical can be your lifetime and 1 million. Your limit would be 1 million over your lifetime (after deductible and coinsurance.
  18. The higher your deductible the _________your premium will be.
  19. What is a Family Deductible?
    Once the medical expenses of the entire family exceeds a certain amount each year, the deductible no longer applies.
  20. What is a Common Accident Deductible?
    If members of the same family are are injured by the same accident, only one deductible charge applies.
  21. What is a Calendar Year Deductible?
    Once you pay a certain amount of expenses out of pocket each year, you will then go straight to coinsurance for all medical expenses the remainder of the calendar year.
  22. What is a Per Person Deductible?
    In a Family Policy, each person has their own deductible to meet each year.
  23. How does a self ensured employer use a Stop Loss policy?
    The company may purchase a Stop Loss policy from a private carrier to protect from catastrophic claims of an employee.
  24. What is the principal objective of an HMO?
    To reduce medical expenses by stressing preventive medicine through physical exams and diagnostic procedures.
  25. What is another word for policyholder in an HMO?
  26. An HMO generally provides services in a __________ or ___________ approved by the Department of Insurance.
    Network or Service Area.
  27. What is a Gate Keeper?
    The same as a Primary Care Physician in and HMO. Your primary doctor.
  28. Under an HMO, what is a co payment?
    The amount you must pay each time to you see the doctor.
  29. In an emergency situation will the subscriber be covered even though their Primary Care Physician is not treating them?
    Yes. But the member must notify their doctor as soon as possible. They must be involved to cover the claim.
  30. What is a Group Practice Model (GPM) in an HMO?
    The HMO contracts with a medical group to provide services to it's HMO members.
  31. What is an Open Panel Medical Group?
    A medical group that provides services to both HMO and non-member patients. Under this plan physicians are not salaried and treat HMO members in their own offices.
  32. What is a Staff Model in and HMO?
    A health care delivery system that is owned and operated by the HMO.
  33. What is the Independent Practice Association Model (IPA) in an HMO?
    A network of individually practicing physicians who contract with the HMO to provide health care services to its members. Unlike a Group Practice Model, IPA are located throughout the service area.
  34. What is a Closed Panel Insurance Model?
    A medical group that provides services only to members of an HMO.
  35. What does PPO stand for?
    Preferred Provider Organization.
  36. What are the benefits of a PPO ?
    • 1. No primary care physician in PPO
    • 2. Broad range of providers covered.
    • 3. If using preferred provider 100% covered+ co pay.
    • 3. Can see any provider at 80/20 + co pay.
  37. What are the benefits of a HMO?
    • 1. Pre-paid Medical care.
    • 2. Select provider only in your service area or network.
    • 3. Primary Care Physician must refer to specialist.
    • 4. Treat everything stressing preventative.
  38. What is Integrated and Non Integrated Dental Insurance?
    Integrated is group policy as part of a larger group medical expense plan. Non integrated is sold as a stand alone policy to an individual.
  39. What does TPA stand for?
    Third Party Administrator. A firm that provides administrative services for employers and other associations having group insurance policies.
  40. Name three things a TPA does.
    • 1. Help submit claims for employees
    • 2. Certify eligibility
    • 3.Prepare reports required by the state
    • 4. Process Claims
  41. What is an Inside Limit?
    An amount predetermined in the policy that limits the benefit to specific treatments such as mental illness, drug abuse.
  42. What is an Impairment Rider?
    Exclusion for specific health conditions or dangerous hobbies you may have.
  43. What is another term for Case Management?
    Utilization Management.
  44. What is the Cost Saving Service in an HMO?
    Provide prevention services to prevent sickness and disease before it happens using various services like prenatal care, screenings and checkups.
  45. What is Perspective Review and give another name for it?
    Also called Pre-Certification, it requires in advance that treatment is necessary before performing it.
  46. What is Concurrent Review?
    Requires a medical monitor to consult with the doctor during treatment in an HMO or PPO
  47. What is Ambulatory Services?
    A possible requirement in Concurrent Review that encourages members to utilize outpatient care in leu of hospitalization.
  48. What is Retrospective Review?
    Requires a medical monitor to review treatment previously provided to determine if it was appropriate under the circumstances.
  49. What is Capitation in an HMO?
    When a provider is paid a set fee per HMP enrollee regardless of how much service they require.
  50. What is a Negotiated Fee For Service?
    An HMO way of paying providers a certain percentage of the expense with the member paying the remaining. With this method the provider is paid a separate fee for each service provided
  51. What is an HMO Salaried Physician?
    On payroll to HMO and have a neutral attitude.No incentive to save or spend money.
  52. What is Fee Scheduled Payments?
    When an HMO pays a physicians group a set scheduled fee for each service provided.
  53. What is a Point Of Service HMO Plan?
    When HMO members go out of the network without approval. Coverage would be at a reduced rate costing the member more.
  54. What is a Managed Indemnity Service HMO Plan?
    Much like an HMO but has fee for service basis, and member is responsible for deductibles and coinsurance. Also,unlimited choice in physicians.
  55. What is the average deductible for an HMO?
    None. There are usually no deductibles in an HMO. PPO is the plan that uses a deductible.
  56. True of False, The lower the deductible the lower the premium?
    False. The higher the deductible the lower the premium.
  57. Which is considered a "pre paid" health plan, HMO or PPO?
    Since the member pays a monthly fee with only a small co pay, HMO is called a Pre Paid plan.
  58. What is coinsurance?
    The part of the medical costs owed by the enrollee.
  59. What prevents over utilization?
    Co-insurance. When the patient has to pay a percentage of each bill they use it less.
  60. What is Tri Care?
    Health insurance for people in the military.
  61. True or False? In an HMO, a primary care physician must pre-authorize all your care except in emergencies.
  62. Long Term Care provides the cost of custodial nursing care but not medical bills. True or False?
  63. AD&D is a limited type of Health Insurance that provides lump sum benefits in case of accidental death and dismemberment. True or False
  64. Disability Income Insurance covers your medical expenses in case you get disabled. True or False.
    False. It only covers lost wages or income not medical expenses.
  65. A PPO can only be started by a Hospital. True or False?
    False. PPO's were started by insurance companies.
Card Set
Medical Expense Plans, HMO, PPO