Health - Ch. 3 - Section 1

3rd type of basic medical expense coverage. commonly written in conjunction with Hospital Expense policies. These policies pay for the costs of surgeons' services, whether the surgery is performed in or out of the hospital. coverage includes surgeons' fees, anesthesiologist and the operating room when it is not covered as miscellaneous medical item. as with other types of basic medical expense coverage, there is no deductible, but coverage is limited.

Each contact has a __________ that lsits the types of operations covered. if the operation is not listed, the contract may pay for a comparable operation. special schedules may express the amount payable as a percentage of the maximum benefit, list a specified amount, or assign a relative value that when multiplied by it's coversion factor gives the benefit payable.

When the __________ approach is used, each surgical procedure will be assigned a number of points that are relative to the number of points assigned to the maximum benefit. the maximum points are usually assigned to major surgical procedures, such as open-heart surgery. the points for this maimum benefit are usually high such as 1,000 points. other surgical procedures such as an appendectomy, may only have an assigned point value of 200.

In order to determine the amt payable for the appendectomy the assigned points (relative value) of 200 are multiplied by a ___________. this __________ represents the total amt payable per point. for example, if the __________ was 10, the policy would pay $2,000 for the appendectomy (200 x 10) and $10,000, the maximum benefit, for the open-heart surgery (1,000 x 10).

Offer a broad range of coverage under one policy. generally, these policies provide comprehensive coverage for hospital expenses (room and board and miscellaneous expenses, nursing services, physicans' services, etc.). these policies are intended to provide the isured with catastrophic medical expense protection. ___________ provide benefits for prolonged injury or illness. coverages include doctors' fees, nurses' fees, hospital room and board, miscellaneous hospital expenses, expenses in connection with cosmetic surgery as the result of an accident. usually a blanket limit with inside limits for specific expenses such as surgical expenses, are provided.

Normally is a lifetime benefit per person limit, and it may have a deductible for each accident/ilness and/or each calndar year and/or each covered person. unlike the basic medical expense plans, these policies usually carry deductibles, coinsurance requirements and large benefit maximums.

Used to supplement the coverage payable under a basic medical expense policy. after the basic policy pays, the __________ will provide coverage for expenses that were not covered by the basic policy, and expenses that exceed the maximum. if the time limitation is used up in the basic policy, the ____________ coverage will provide coverage thereafter.

The basic expense policy will provide coverage on a first-dollar basis (on deductible). after the limits of the basic policy are exhausted, the insured must pay a ___________ before the major medical coverage will pay benefits. the __________ derives its name from the fact that it is applied between the basic coverage and the major medical coverage.

A combination of basic expense coverage and major medical coverage, sold as one policy. they cover practically all medical expenses, hospital, physicians, surgical, nursing, drugs, laboratory tests, etc. some benefits in __________ include a deductible, while others do not. provides the first dollar coverage provided by basic coverage followed by a corridor deductible, then the high limits of coverage under major medical.

Increasing health care costs during the 1970s and 1980s helped stimulate the rapid growth of __________. established to manage health care and the associated costs by providing prepaid care that emphasizes preventive care. this is quite a departure from traditional health insurance policies that typically did not cover preventive care, covering illness only after it has manifested.

Regarded as an organized system of health care that provides a comprehensive array of medical services on a prepaid basis to voluntarily enrolled persons living within a specified geographic area (called srvice area). insureds(calle subscribers) pay a premium to the __________ and ae provided with a borad range of health care services, including routine doctor visits and emergency room care.

HMO is organized by which physicians or hospitals provide the health care. HMOs can be organized according ot four different models:group model, staff model, netowkr model and association model. HMOs may be identified as either open panel or closed panel.

Under this arrangement, the HMO contracts with an independent medical group that specializes in a variety of medical services. the HMO pays the gorup rather than the individual physicians. the medical group in turn, decides how to pay the individual physicians.

Sometimes the HMO will pay the medical group a __________, which is fixed monthly amount per member of the HMO. since it is a fixed amt, the gorup can profit from members who utilize very little srvies, and possibly loose money on members who utilize the HMO service frequently. therefor, the medical group assumes some financial risk under the the group model.

Physicians are acutally paid employees of the HMO. the HMO typically will have its own physical facility at which the physicians provide their services. sometimes the HMO will even own and operate a hosptial. since the physicians are salaried employees of the HMO, they are under no financial risk.