风险管理与保险原理 课后题答案part17

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

59

Chapter 17: Loss of Health 60

Patient’s Bill of Rights

Direct Access to Specialists

Definition of an Emergency

Liability Provisions

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,

are provided with comprehensive health services by physicians associated with the HMO. A

POS plan is similar to an HMO, but allows more freedom in the selection of doctors and other

medical care providers. A PPO is an organization in which the health care providers agree to

give a discount from their usual fees in exchange for promises from the participating employers.

2. a. In a group practice HMO, a large group of physicians share facilities and support personnel

and work out of one or a few locations. The physicians are not employees of the HMO, but

have a contractual relationship with it.