IMch17 - CHAPTER 17 Loss of Health HEALTH INSURANCE...

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CHAPTER 17 Loss of Health HEALTH INSURANCE PROVIDERS Insurers and the Blues Health Maintenance Organizations Point-of-Service Plans Preferred Provider Organizations Medicaid and Medicare MECHANICS OF COST SHARING Deductibles Copays Coinsurance Caps Maximum Limits HEALTH EXPENSE INSURANCE Hospital Insurance Surgical Insurance Regular Medical Expense Insurance Major Medical Insurance Dental Insurance Long-Term Care Insurance Medicare Other Health Expense Insurance DISABILITY INCOME INSURANCE Benefit Duration Definition of Disability Elimination Period Benefit Level HEALTH INSURANCE POLICY PROVISIONS Continuation Provisions Mandatory Provisions Grace Period and Reinstatement Claims Miscellaneous Optional Provisions Occupation Misstatement of Age Other Insurance Miscellaneous HEALTH CARE REFORM Guaranteed Access to Health Care Health Savings Accounts Minimum Required Benefits Patient’s Bill of Rights Direct Access to Specialists Definition of an Emergency Liability Provisions 1
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Other Proposed Restrictions Any Willing Provider Laws Anti-Gag Provisions KEY TERMS AND CONCEPTS Activities of daily living (ADLs) Ancillary charges Any occupation for which reasonably suited Any willing provider (AWP) laws Basic health insurance policies Blue Cross and Blue Shield associations Cancellable Capitation basis Coinsurance cap Comprehensive Conditionally renewable Continuation provisions Copay Dental insurance Disability income insurance Elimination period Excess major medical Fee-per-service basis Gatekeepers Group practice HMO Guaranteed renewable Health maintenance organizations (HMOs) Hospice Hospital insurance Individual practice HMO Internal maximums Lifetime maximum Long-term care (LTC) insurance Long-term disability (LTD) insurance Major medical insurance Medicaid Health Savings Accounts (HSAs) Medicare Medigap insurance Noncancellable Nonscheduled basis Open-ended HMO Optionally renewable Out-of-pocket cap Own occupation Per-cause deductible Point-of-service (POS) plan Preferred provider organizations (PPOs) Primary care physician Reasonable and customary Regular medical expense insurance Residual disability Scheduled basis Short-term disability (STD) insurance Staff model HMO State mandated coverages Supplementary medical insurance Surgical insurance Term contract ANSWERS TO QUESTIONS FOR REVIEW AND DISCUSSION 1. The types of health insurance providers are commercial insurers, Blue Cross and Blue Shield associations (the Blues), health maintenance organizations (HMOs), point-of-service (POS) plans, and preferred provider organizations (PPOs). The Blues are independent groups established by health care service providers set up to prepay some types of health care expenses. HMOs are programs in which the members, who live within a well-defined geographical area,
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IMch17 - CHAPTER 17 Loss of Health HEALTH INSURANCE...

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