| A | B |
|---|
| Medical Expense Insurance | Basic hospital, surgical and medical policies and major medical policies grouped together. |
| Basic Hospital Expense Coverage | Covers hospital room and board, and miscellaneous hospital expenses, such as lab and x-ray charges, medicines, use of operating room and supplies, while the insured is confined to a hospital, with no deductible and the limits on room and board are set at a specified dollar amount per day up to a maximum number of days. |
| Miscellaneous Hospital Expenses | Usually expressed as a multiple of the daily room and board limit for example 10 or 15 times the daily room and board limit. However, it can also be expressed as a flat benefit or as a percentage of participation. The benefits provided by this coverage are drugs, x-rays, and laboratory expenses |
| Basic Medical Expense Coverage | This is often referred to as Basic Physicians Nonsurgical Expense Coverage because it provides coverage for nonsurgical services a physician provides. The benefits are usually limited to visits to patients confined in the hospital and some policies will also pay for patient office visits. |
| Basic Surgical Expense Coverage | These pay for the costs of surgeon’s services, whether the surgery is performed in or out of the hospital. Each contract has a surgical schedule which lists the types of surgery it will cover and the amount that will be paid for that surgery. No deductible, but coverage is limited so most people would be better off purchasing a major medical policy. |
| Major Medical Policies | These policies provide comprehensive coverage for hospital expenses. These policies are intended to provide the insured with catastrophic medical expense protection. Include deductibles, but have high maximum limits. Policies are usually written on a lifetime basis, provide coverage under one policy up to a stated limit for the “lifetime” of the policy |
| Major Medical Policy Exclusions | Injuries due to war or military conflict; Elective cosmetic surgery; Dental care (except due to accident); Eye examinations and eyeglasses, hearing examinations and hearing aids; Pregnancy and childbirth (except complications of pregnancy); Treatment received in a federal or state hospital; Accidents that would be covered under Workers Compensation; War; Self-inflicted injury; Military Duty; Eye refractions |
| Comprehensive Medical Expense | Combination of basic medical expense coverage plus a major medical plan |
| Corridor | Deductible that connects a first dollar plan to a major medical plan |
| Impairment Rider | Indicates who/what is not covered |
| Guaranteed Insurability Rider | Provides the insured with the right to purchase additional disability income benefits without evidence of insurability |
| Multiple Indemnity Rider | Provides double or triple benefits if injury is sustained under certain circumstances |
| Fee for Service | A payment system for health care in which the provider is paid for each service given. |
| Prepaid Plans | Plan subscribers pay a set fee, usually each month, for medical services covered under the plan. Blue Cross and Blue Shield plans are prepaid plans |
| Benefit Scheduled versus Nonscheduled Plans: | Scheduled benefit plans include a schedule that lists major commonly performed operations and benefits payable for each |
| Cancellable | Health insurance policies provide the insurer with the right to cancel at any time by giving the insured a specified number of days notice (usually as little as five days notice). |
| Noncancellable | Contract cannot be cancelled by an insurer for any reason except nonpayment of premium. Insureds may cancel these policies if and when they wish. Noncancellable contracts provide the insured with a stated amount of coverage for a stated period of time (usually to age 65) at a guaranteed premium rate |
| Guaranteed Renewable | These contracts will continue health protection, but may not continue at the same premium charge. |
| Conditionally Renewable | These policies provide the insurer with the right to refuse to renew coverage for certain conditions stated in the policy. |
| Optionally Renewable | These policies provide the insurer with the right or option to renew or terminate an individual policy at the time of premium payment |
| Commercial Insurers | Function on the reimbursement approach; that is policyowners obtain medical treatment from whatever source they choose and are reimbursed |
| Blue Cross & Blue Shield | Their policyholders are called subscribers and those subscribers visit medical care providers that have an agreement as to the charges for this care |
| ultiple Employer Trusts and Multiple Employer Welfare Arrangements | Under this type of program, a small business can subscribe and this puts the business in a “group” with the lower premium benefit of a group. |
| Preferred Provider Organizations (PPOs) | Physicians are paid fees for their services rather than a salary, but the member is encouraged to visit approved member physicians that have previously agreed upon the fees to be charged. |
| Health Maintenance Organizations (HMOs) | Provide coverage to patients “in-network”. Meaning, subscribers can only visit health care providers that belong to the organization |
| Open-panel HMO | All health care providers can work for the HMO as long as they agree to the requirements. They usually work out of their own offices and usually represent the HMO on a part-time basis, seeing both HMO patients and non-HMO patients |
| Closed-panel HMO | Providers work for the HMO and provide services at an HMO facility |
| Group Model of HMO | The HMO contracts with an independent medical group that specializes in a variety of medical services |
| Staff Model of HMOs | Physicians are actually paid employees of the HMO |
| Network Model of HMOs | Similar to the group model except that the HMO contracts with two or more medical groups instead of just one. |
| Independent Practice Association Model of HMO | Physicians are actually paid employees of the HMO. The physicians are paid on a fee-for-service basis whereby the fees have been negotiated in advance |
| Skilled nursing care | Daily nursing and rehabilitative care that can only be provided by medical personnel, under the direction of a physician |
| Intermediate care | Occasional nursing and rehabilitative care provided by medical personnel. Patient needs care daily, but not 24-hour care. |
| Custodial care | Care for meeting personal needs such as assistance in eating, dressing, or bathing, provided under a doctor’s orders, but by non-medical personnel |
| Home health care | Care provided in one’s home |
| Home Convalescent care | Care provided in the insured’s home under a planned program established by his or her attending physician. |
| Residential Care | Care provided while the insured resides in a retirement community |
| Adult day care | Care provided for functionally impaired adults on less than a 24-hour basis. It could be provided by a neighborhood recreation center or a community center. Care includes transportation, and a variety of health, social and related activities. Meals are usually included as a part of the service |
| Respite care | Designed to provide relief to the family care giver, and can include a service such as someone coming to the home while the care giver goes out for a while |
| Medicare Supplement Insurance/ Medigap | Policies issued by private insurance companies that are designed to fill in some of the gaps in Medicare |
| Medicaid | A federal and state funded program for those whose income and resources are insufficient to meet the cost of necessary medical care |
