Term
| Prepaid vs Imdemnity Plans |
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Definition
Prepaid Service Plans-Set allowance-paid directly to provider-Hosp(BC),Medical(BS)-non profit
Indemnity plans reimbursed a set dollar amount to the subscriber-for profit |
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Term
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Definition
| Subscriber pays no expense--no used today--cost containment used to encouragesuscriber to share in cost of insurance |
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Term
| Types of Hospitalization Benefits covered today |
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Definition
Inpatient R&B
Emergency
Intemsive Care
Maternity
X-Ray
Radiation
Inpatient mental & nervous, drug, alcohol
Phys therapy
Home care, hospice, respite |
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Term
| Types of Medical benefits covered today |
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Definition
Surgeons
Anesthesiologist
Nouse
Second Opinions
X-ray
Allergy testing
Immunnization-Children
Standard care |
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Term
| Early Cost sharing Tech used in Major Med coverage |
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Definition
Deductibles-subscriber pays before plan starts paying
Co-insurance-cost sharing % |
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Term
| Pros/Cons for Deductibles,Co-insurance |
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Definition
Pro--
May reduce use=reduce costs
May reduce premiums
Creaty equity-ind cost related to use
Cons--
May reduce utilization of services
May discourage preventative care
Present a barrier to needed care |
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Term
| Major Medical-How it works |
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Definition
| Ofter combined with first dollar prepaid service-in early plans-second level of reimbursement-must have lifetime and annual maximums |
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Term
| Comprehensive vs Major Medical Plans |
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Definition
| Comprehensive are an adaption of MM approach.Upfron deductibles and co-insurance applied to all hospital and medical services-subscriber shares in costs |
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Term
| Comprehensive plans-Other Cost Controls |
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Definition
Second Surgical opinions
Full coverage for disgnostic tests
Preadmin certification
Utilization review
Incentives for using outpatient |
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Term
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Definition
Co-insurance
Deductibles
Copayment
Premium contributions by employees |
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Term
| COB-Coordination of Benefits |
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Definition
| To prevent duplication-primary plan is parent whose birthday is first(Birthday Rule) Company without COB pays first--other pays balance of loss |
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Term
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Definition
Subrogation-substitution of another party
Preadmin testing-to help contain hospital costs
Elim weekend admissions
Medical necessity language
Skilled nursing care
Home health care |
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Term
| Ensure Preadmission Testing |
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Definition
| Benefit pland reduces benefits if not done or penalty imposed |
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Term
| Manage Care Arrangements(3)-covers & not Traditional Plans |
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Definition
HMO's
PPO's
POS's
Include routine physical exams, preventive screenings, diagnostic test, prenatal care, vision, dental and health clubs |
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Term
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Definition
IPM-Individual Practice Model
GM-Group Model
NM-Network Model
SM-Staff Model |
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Term
| Rating Techniques evolution |
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Definition
Community rated byindustry/region
Larger companies want experience rating-based on past claims and utilization
Adjusted community rating-selective |
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Term
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Definition
| Med max must apply to mental health & drug addiction as with the policy but can limit number of treatments |
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Term
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Definition
| Ofeth used with self insured plans to limits organization exposure if predetermined amount exceeded |
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Term
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Definition
| Pays HMO a certain amount per head whether subscriber uses services or not |
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