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What is an HMO?
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A health maintenance organization (HMO) is an organization that provides comprehensive health care to a voluntarily enrolled population at a predetermined price. Members pay fixed fees directly to the HMO and in return receive health care services as often as needed.
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What is a PPO?
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A preferred provider organization (PPO) is an association that contracts with a group of doctors, dentists, hospitals or other health care service providers to provide care at prearranged rates or discounts.
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What is a base plus plan?
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A base plus plan is a two part health insurance plan. Basic medical coverage – for such expenses as hospitalization, surgery, physicians visits, diagnostic lab tests and x-rays – is provided under the first part. There may be limits on these expenses, such as a limited number of hospital days and a surgical schedule, but no deductible or coinsurance applies to the covered expenses. The second, or major medical, part of the plan covers. Other health expenses. The coverage is broad, with fewer limits; however a deductible is required for reimbursement of expenses.
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What is a comprehensive plan?
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A comprehensive plan provides coverage for most medical services using one reimbursement formula. In a pure comprehensive plan, a deductible must be met before reimbursement for any covered expenses begins, and coinsurance applies to all covered expenses until the maximum out-of-pocket expense limit is reached. After that, additional covered expenses are normally paid in full. |
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What kind of hospital outpaitient expenses are covered?
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Three kinds of care are covered: emergency treatment, surgery and services rendered in the outpatient lab or x-ray department.
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What types of services are generally covered by a group health insurance plan?
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Plans vary by insurer, but generally cover the same kinds of service. These include:
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| Professional services of doctors and other recognized medical practitioners |
| Hospital charges for semiprivate room and board |
| Hospital services and supplies |
| Surgical charges |
| Services of RNs and in some cases, LPNs |
| Home health care |
| Physiotherapy |
| Anesthetics and their administration |
| X-rays and other diagnostic lab procedures |
| X-ray or radium treatment |
| Oxygen and other gases and their administration |
| Blood transfusions |
| Drugs and medicines requiring a prescription |
| Specified ambulance services |
| Rental of durable mechanical equipment required for therapeutic use |
| Artificial limbs and other prosthetic appliances |
| Cast, splints, trusses, braces and crutches |
| Rental of a wheelchair or hospital-type bed |
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What is a deductible?
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It is a specific dollar amount that an individual must pay before reimbursement for expenses begins. The higher the deductible, the lower the cost of the health insurance plan.
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What is coinsurance?
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It is a feature found in most group health plans. It sets forth the percentage of covered expenses that you and the health insurance plan will pay. The most common coinsurance level is one in which you pay 20% and the insurer pays 80%. This is called 80% coinsurance.
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What is covered expense and are there limits?
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A covered expense is an eligible expense under the plan. It is an expense incurred by a covered individual that will be reimbursed in whole or in part under the insurance plan. Example: Under most plans, doctor’s visits are a covered expense, i.e., a doctor’s fee up to the amount provided by the plan will be reimbursed by the insurer. Just because an expense is covered does not mean that the coverage is unlimited. Most plans have limits on the expenses for which they will reimburse and most have some fore of deductible and coinsurance applicable.
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Do health insurance plans cover dental care?
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Traditionally dental coverage has not been included. Some plans do cover dental care particularly when dental work is necessary as the result of an accident. Some plans include limited coverage for hospital board and room as well when the procedure is conducted in a hospital.
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How is vision care covered?
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Most health insurance plans provide coverage for medical care related to eye injury or disease, but do not cover the costs of periodic eye exams or corrective lenses.
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Are all prescription drugs covered under health care plans?
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Generally, only prescription drugs that are for treatment of an illness or injury are covered, subject to applicable deductibles and coinsure. Many plans do not cover contraceptive prescription drugs, e.g., nicotine chewing gum prescribed for smokers who are trying to quit.
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Are there different types of drug plans?
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There are literally thousands of variations, but the principal types of prescription medication plans are open panel, closed panel, mail order and prescription drug card plans.
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