风险管理与保险原理 课后题答案part17

59 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 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. Chapter 17: Loss of Health 61 b. A staff model HMO also operates out of one or a few locations, but the doctors are employees and are paid a salary by the HMO. c. An individual practice HMO does not operate out of a centralized location; instead, the physicians operate out of their own offices. A POS (point-of-service) plan is similar to an HMO except individuals are given the choice to use a medical care provider outside of the system if they pay for a larger share of their medical bills. 3. The sponsoring organization might promise to provide a minimum number of patients each month, pay promptly, and encourage participants to take advantage of health education programs. 4. a. $0 (Smith has not yet met the deductible). b. $100 (After meeting the $1,000 deductible, the insurer will pay 80 percent of the remainder). c. $2,200 (80 percent of $2,750). d. $2,480 (80 percent of $3,100). e. $38,695 ($42,500 less the remaining coinsurance amount). 5. a. $400 (80 percent of the quantity $750 – $250). b. $100 (80 percent of the quantity $375 – $250). c. $2,200 (80 percent of $2,750). d. $2,480 (80 percent of $3,100). e. $39,295 ($42,500 – $5,000 cap + $1,795 already paid by John this year). 6. Insurers determine “reasonable and customary” fees by analyzing the range of fees prevailing in the relevant geographical area at the time that the surgery is performed. Fees in excess of those charged by others in the region will be found to be more than the reasonable and customary amount. 7. Surgical policies written on a scheduled basis contain a listing of several surgical procedures together with a maximum payable for each procedure. Those written on a nonscheduled basis cover insured procedures up to the full amount of what is considered to be reasonable and customary. Generally, it is better for the insured to have a policy written on a nonscheduled basis. 8. A comprehensive form of a major medical policy is designed to replace basic health coverage and to insure all medical expenses within the same policy. 9. The important points that should be considered are: whether the spouse of the named insured is also covered, the conditions necessary to trigger benefit payments, whether the daily maximum and the overall policy limit will increase over time, whether the overall limits can be restored and under what conditions, selection of an elimination period, whether the plan covers custodial care as well as skilled and intermediate nursing home care, whether losses related to Alzheimer’s disease are excluded, and whether hospitalization immediately prior to entering a long-term care facility is required. 10. Part A of Medicare is the hospital insurance that covers inpatient hospital care, skilled nursing home care, home health services, and hospice care. Part B is referred to as the supplementary medical insurance that covers doctors’ bills and related expenses. Medigap insurance provides coverage for medical care that is not covered by Medicare because of deductibles, coinsurance, and coverage limitations. Under Medicare reform legislation passed in 2003, optional prescription drug coverage for Medicare beneficiaries will be available beginning in 2006. The monthly premium for the prescription drug coverage will initially be about $35. The plan will have a $250 deductible. After that, the beneficiary will pay 25 percent of the cost for drug costs up to $2,250. The beneficiary is then responsible for all drug costs between $2,250 and $3,600. For drug costs exceeding $3,600, the beneficiary will pay 5 percent of costs or a modest copayment. 11. Disability income insurance can be distinguished from other forms of health insurance because, rather than covering specified medical or other health expenses, disability income insurance