1. Basic Medical Expense policies
Answer: Provide coverage for Hospital, Surgical andPhysicians Medical Expense.
-Purchased as a individual or group policy.
-provide first dollar coverage (no deductibles).
-limited benefit periods and low coverage limits.
2. Major Medical Expense Policy
Answer:
-A supplement (in addition) to Basic Medical oras a stand-alone policy.
-individual or group policy.
-Take over when the Basic Policy runs out
3. Hospital Expenses
Answer: -Pay for covered expenses incurred during a hospital stay.
1. Daily hospital benefit - Room and Board
2. Miscellaneous expenses - Other Medical Expenses (X-Rays, MRI, Prescriptions,Doctor
Visits)
4. Daily Hospital Benefit
Answer: -Cost of a hospital room, up to a daily $ limit. The limit maybe expressed either as a
dollar amount, e.g. $500 per day, or it may be expressedas the Usual, Customary and
Reasonable (UCR) and Charge
5. Usual, Customary and Reasonable (UCR)
Answer: Insurance company will pay an amount for a given procedure based upon the
average charge for that procedure in that specific geographic area. The coverage is subject to a
maximum amount ornumber of days.
6. Benefit Schedule
Answer: -Specifically states what is covered in the plan and for howmuch. The coverage is
subject to a maximum amount or number of days.
7. Indemnity
Answer: Insured pays the bill and is reimbursed by the insurance company upto a specified
limit amount. Medical expense policies that pay a fixed rate provide the insured with a stated
benefit amount for each day of hospital confinement.
8. Reimbursement
Answer: Policyowners obtain medical treatment from whatever sourcethey want and submit
their charges to their insurer for reimbursement (actual amount).
, 9. Service Based Contracts
Answer: -Pay doctors and hospitals directly according to the# of days of coverage that is
provided in the contract for each event and are prepayment plans. Once a claim is settled, the
insured will receive an Explanationof Benefit (EOB), which is a written confirmation that the
claim was paid. Blue Cross and Blue Shield, Health Service Corporations and Medicare
coverage are all provided on a Service Basis.
10. Miscellaneous Expense Benefits
Answer: -Secondary benefits (inside benefits) be- cause they occur inside the hospital for
charges related to the stay. X-rays, prescriptions, MRI's, anesthesia and lab fees are usually
separate fees incurred duringa stay. Miscellaneous Expense Benefits have separate limits,
referred to as Inside Limits. The are expressed usually as a multiple of the daily amount
(UCR)
11. Surgical Expense
Answer: A schedule of procedures lists the amount allowable for each procedure. If a surgical
procedure is not found in the schedule, it will still be payable. The amount payable for a
procedure not listed is based on its relative valueto a procedure of similar difficulty. There are
usually no deductibles.
12. Surgical Schedule
Answer: Is simply a price list. Each procedure is listed and a dollaramount assigned and if a
procedure is not listed in the schedule it is still paid.
13. Relative Value
Answer: scientific method of paying different benefits based on the regionof the country an
insured lives. It is based on assigning a value to each procedure and using a conversion factor.
A schedule of assigned points for each procedure must be included in the policy.
14. Physicians Medical Expense
Answer: Pays for visits to the doctor (office hospital) pluspost operation care. There may be a
per-visit benefit, or the coverage is based on UCR.
-May or may not be a deductible . This policy is usually written as an indemnity planand has
first dollar coverage (no deductible).
-usually written as an indemnity plan and has first dollar coverage
15. Major Medical Expense
Answer:
-Cover "catastrophic" or huge loss. A Catastrophicloss is defined as whenever Basic coverage
runs out and not a specific dollar amount.
-High Maximum Limits ($2,000,000)
-Deductibles (per person or per family ea yr))
-Co- insurance (Usually 80/20%)
-Stop Loss
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