Unit 16 Medical Expense PLans

Fee for Service

Provider is paid as services are rendered; customers called insureds

Prepaid Plan

Provider is paid a set fee in advance; customers called subscribers/participants

Specified Coverage

Covers only specific services

Comprehensive Care

Covers a broad range of services

Benefit Schedule

Pays only a specified amount, regardless of actual charges

Usual, Customary, Reasonable (UCR)

Pays the full charge if it's reasonable and customary for the geographic area

Any Provider Plan

Insured may choose any provider

Limited Choice Plan

Limited to contracted providers

Basic Hospital/Medical/Surgical Policy

Low coverage amounts with no deductibles

Supplemental Major Medical

Pays after a basic policy's coverage ends

Comprehensive Major Medical

A stand-alone major medical policy

Major Medical Covered Expenses

Includes hospital room/board, surgical services, nursing, outpatient care, X-rays, prescription drugs, prosthetics, home health care, and hospice care

Hospice Care

Terminal illness care providing pain relief, symptom management, and counseling, but no curative treatment

Deductible (Major Medical)

Amount paid by the insured before the policy begins paying, usually on a calendar-year basis

Coinsurance

Insured continues to pay a portion of the bill after the deductible (commonly 80% insurer/20% insured)

Stop Loss

The point at which the insured no longer shares in costs once bills exceed a certain amount

Maximum Out of Pocket

Deductible plus coinsurance combined

Major Medical Exclusions

Self-inflicted injuries, war, active military duty illness/injury, non-passenger air travel injury, felony-related injury, experimental procedures, workers' comp-covered care, government facility care, elective cosmetic surgery, hearing aids, and custodial care