Initial amount client must pay before insurance coverage begins.
Coinsurance (participation percentage)
Defines what portion of covered medical expenses is paid by the insured and what portion is paid by the plan, up to a maximum (or breakpoint)
the amount of covered expenses, beyond the deductible, that is shared at the coinsurance rate
the dollar amount of the deductible combined with the stop-loss limit, which is the point after which an insurer begins to pay 100% of all covered medical expenses up to the plan max
the payment of an annual or monthly fee to providers, rather than the payment of a fee-for-service (think HMO)
proposed procedure is reviewed and authorized by the insurance company before it occurs or (if an emergency) within a specified period of time afterward.
UCR Table/ surgical schedule
(usual, customary, and reasonable amount for a service) max amount the insurer will pay for a service in a given area
Internal policy limits
limits for specific illnesses or procedures that fall below policy overall benefits
modified or additional medical (or dental/vision) coverage available for an extra premium
coordination of benefits clause
prevents insured from collecting from multiple policies in such a way that recovers more than 100% of medical costs
Medical expense indemnity insurance plan: hospital expense coverage
can either cover all or some of the room and board (hospital indemnity contract), or covers actual services of hospital for stated number of days (hospital service contract)
Medical expense indemnity insurance plan: surgical expense coverage
pays a portion of physician's fees for surgical care
Medical expense indemnity insurance plan: physician's expense reimbursement insurance
pays a portion of physician's fees for non-surgical care
Medical expense indemnity insurance plan: Major medical coverage
high limit per loss and is relatively free of exclusions; designed to protect against large losses; coverage takes over when base plan's limits are met; contains a deductible, a coinsurance provision and a stop-loss limit.
Medical expense indemnity insurance plan: comprehensive major medical coverage
same as major medical coverage, but designed to be purchased as stand alone coverage (without a base plan). In practice, it is like purchasing one policy that provides coverage similar to piecing together the other types of medical expense indemnity insurance plans.
Main way that HIPAA reduced "job lock"
disallows preexisting condition exclusion if insured was previously covered for at least 12 months (18 months for late enrollees) and no gap in coverage exceeding 63 days. Otherwise, the preexisting condition exclusion can only be in effect for however many days the insured was short of the necessary previous coverage period. If a plan has a waiting period for new hires, the preexisting conditions exclusion must also be reduced by the number of days equal to the waiting period.
When are COBRA benefits available for 18 months?
event of termination or loss of benefits due to change to part-time status
When are COBRA benefits available for 29 months?
extension in the event of disability
When are COBRA benefits available for 36 months?
divorced spouses, inured spouse qualified for medicare, or loss of dependent status
What are the four parts of Medicare and what general coverage does each part offer?
Part A: hospital coverage
Part B: Physician's and out-of-hospital coverage
Part C: Medicare Advantage - alternatives to traditional medicare coverage (Medicare HMO, PPO, Private fee-for service, Special needs plan, Medicare MSA)
Part D: prescription drug coverage.
Medicare MSA vs. HSA
MSA starts at age 65, the contributions are not made by the participant, and only available to medicare part C enrollees; HSA available to individuals/families and contributions can only be made until 65 by the participant
Term used to describe private insurance that is purchased to supplement Medicare coverage
- Point-of-Service plan
- Hybrid of HMO and PPO
- Covers treatment of an HMO provider as with an HMO plan
- Permits patient to seek care outside HMO plan but at high out-of-pocket costs
a type of managed care health insurance plan that utilizes a network of physicians and facilities contracted by the insurance carrier to provide services within negotiated price boundaries. (Unlike HMO, you can get healthcare at other physicians)
Health maintenance org, you pay a monthly fee directly to health care provider (vs. insurance company) and all medical services must be provided by the HMO (except in emergencies). Your primary-care physician also serves as a "gatekeeper" for your medical services.
Provider service network
A service network that is operated by providers and funded in part by the
capital contribution of its members. A PSN is designed to operate like an
HMO but is exempt from being regulated as an insurance company.
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