Chapter 5 Medical Plans

Fee for service is a payment system for Health Care where the provider is paid for each service given. This means that the healthcare provider receives payment for each individual service they provide to a patient, rather than receiving a fixed amount or a pre-determined lump sum. This type of payment system is commonly used in healthcare settings where services are billed separately, allowing for more flexibility in reimbursement and payment for specific services rendered.

Based on the information provided, Crystal's Medical Expense Plan has a 60/40 coinsurance after the deductible is met. This means that after Crystal met the $200 deductible, the insurer would pay 60% of the remaining costs, while Crystal would pay 40%. Since $7,200 in costs remained after the deductible, the insurer would pay 60% of $7,200, which is $4,320, and Crystal would pay 40% of $7,200, which is $2,880.

If a non-PPO doctor is used for services, a PPO will not pay the full amount of a charge. This is because PPOs have a network of preferred providers, and if a non-PPO doctor is used, the PPO may only cover a portion of the charge or may not cover it at all. Using non-PPO doctors often results in higher out-of-pocket expenses for the patient.

A pre-existing condition is a condition that an employee has sought medical advice, diagnosis, or treatment for within the previous 6 months. This means that if the employee has received any medical attention for a specific condition within the last 6 months, it would be considered a pre-existing condition.

A managed care plan involves the financing, management, and delivery of health care services. It is a type of health insurance plan that focuses on coordinating care and controlling costs. This type of plan usually requires individuals to choose a primary care physician and obtain referrals for specialist care. The primary goal of a managed care plan is to provide comprehensive and cost-effective health care services to its members.

The main purpose of getting a referral from a gatekeeper, so a subscriber can see a specialist, is to contain costs. This means that the referral system helps in managing and controlling healthcare expenses by ensuring that patients only see specialists when it is necessary and appropriate. By requiring a referral, unnecessary specialist visits can be avoided, leading to cost savings for both the patient and the healthcare system.

If your Health Care plan has characteristics of an HMO and a PPO, you have a POS (Point of Service) plan. A POS plan combines features of both HMO and PPO plans, allowing you to choose a primary care physician within the network like an HMO, but also giving you the flexibility to see out-of-network specialists without a referral, similar to a PPO. With a POS plan, you have the option to receive care from both in-network and out-of-network providers, although out-of-network care may require higher out-of-pocket costs.

Under HIPAA, coverage may be nonrenewed for reasons such as nonpayment of premium, noncompliance with plan provisions, and failure to fulfill participation requirements. However, frequency of claims is not a valid reason for nonrenewal under HIPAA.

PPO physicians are paid a fee for each service they provide. This means that they receive payment for each individual medical service they offer to their patients. This payment structure allows them to be compensated for the specific services they perform, rather than receiving a monthly salary or being paid only when providing services in a specific geographic area.

Basic Medical plans do not provide coverage for catastrophic medical expenses. This means that if an individual incurs a significant medical expense, such as a major surgery or a prolonged hospital stay, the basic medical plan will not cover the costs associated with these catastrophic events. Instead, coverage for catastrophic medical expenses is typically provided by more comprehensive insurance plans, such as high-deductible health plans or comprehensive medical plans.

A Major Medical Plan typically includes coinsurance, a deductible, and high maximum limits. These are primary characteristics of such a plan. However, the absence of catastrophic protection is not a primary characteristic. Catastrophic protection refers to coverage for major medical expenses, such as those resulting from a serious illness or injury. While it is desirable to have catastrophic protection in a Major Medical Plan, its absence does not exclude a plan from being classified as a Major Medical Plan.

A prospective review is an advance utilization management tool used to determine if a procedure is covered under a Health plan. It involves reviewing the medical necessity and appropriateness of a proposed treatment or procedure before it is performed. This helps to ensure that the procedure is necessary and cost-effective, and helps to prevent unnecessary or inappropriate treatments.

A Limited Accident Policy is a type of insurance policy that provides specific benefits for specific injuries that occur from specific causes. This means that the policy will only cover injuries that are specifically listed in the policy and caused by specific events or accidents. It does not provide coverage for any other types of injuries or accidents.

Concurrent Review is a Case Management Provision used by insurers to monitor hospital stays. It involves the ongoing review of a patient's medical treatment while they are still in the hospital. This allows the insurer to ensure that the care being provided is necessary and appropriate, and to make any necessary adjustments or recommendations. Concurrent Review helps insurers manage costs and ensure quality of care by actively monitoring and coordinating the patient's treatment plan during their hospital stay.

A Certificate of Coverage is a document that provides proof of health insurance coverage. It is typically issued by an insurance company to an individual or employer. The purpose of a Certificate of Coverage is to reduce the 1 year waiting period for pre-existing conditions. This means that individuals who have pre-existing conditions can receive coverage for those conditions sooner, without having to wait for a full year.

The employer determines the eligibility and contribution limits to a Health Reimbursement Account. This is because the employer is the one who establishes and manages the HRA program for their employees. They set the criteria for eligibility and determine how much money can be contributed to the account. The employee's role is to participate in the program and use the funds for eligible healthcare expenses.

Insurers include provisions in contracts to help reduce unnecessary claims and the overpayment of claims. The Consideration Clause is not one of those provisions. The Consideration Clause is a common element in contracts that requires both parties to provide something of value in exchange for the contract to be valid. It is not specifically related to reducing unnecessary claims or overpayment of claims.

Catastrophic loss is not an exclusion from Major Medical policies. Major Medical policies typically cover a wide range of medical expenses, including hospitalization, surgeries, and prescription medications. Catastrophic loss refers to a situation where a person experiences a significant financial loss due to a catastrophic event, such as a natural disaster or a major accident. While Major Medical policies may not cover all types of catastrophic losses, they generally do not exclude them as a whole.

Eligible health plans offer high maximum benefits, which means that there is a high limit on the amount of coverage provided for various medical expenses. This ensures that policyholders have access to a significant amount of financial support in case of costly medical treatments or emergencies. With high maximum benefits, individuals can receive comprehensive coverage and have peace of mind knowing that their healthcare expenses will be adequately covered.

Eligible plans are major medical insurance plans that cover expenses both in and out of medical facilities. These plans typically provide coverage for a wide range of medical services, including hospital stays, doctor visits, prescription drugs, and preventive care. Eligible plans often have a network of preferred providers, but they also allow policyholders to receive care from out-of-network providers, although at a higher cost. These plans are designed to provide comprehensive coverage and protect individuals from high medical expenses.