Medical Expense Policies and Managed Care

What this video covers

• How basic hospital coverage, basic medical-surgical coverage, combined base packages, and major medical differ
• What deductibles, copayments, coinsurance, exclusions, and cost sharing mean
• How to calculate a scheduled benefit using actual covered days and listed services, and why a policy maximum is not an automatic payment
• How health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS) plans commonly differ in networks and referral rules
• How referrals can change member costs, and how allowed amounts and balance billing affect what the insured owes
• How preauthorization, concurrent review, and case management work, and why authorization does not guarantee claim payment
• How to calculate out-of-network costs, including coinsurance and a permitted balance bill, while checking applicable protections and contract terms