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57 Cards in this Set
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Medical Expense Insurance |
Basic hospital, surgical, medical policies, and major medical policies as a result of accident or sickness |
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Basic Medical Expense Coverage |
Non surgical services a physician provides. No deductible, room and board set at specific price |
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Relative Value |
Assigned a number of points that are relative to the number of points assigned to the max benefit of a surgical procedure |
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Supplementary Major Medical Policies |
Supplements the coverage payable under a basic med expense policy. |
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Corridor Deductible |
After the limits of the basic policy are exhausted, insured pays this before major medical kicks in. |
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Health Maintenance Act of 1973 |
Congress supported the growth of health maintenance orgs (HMO) for those with 25 employees or more who lived in certain areas, otherwise ineligible. |
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HMO |
Providers benefits in the form of services rather than reimbursement. Unique because it Provides financing and patient care for it's members. |
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Primary Care Physician PCP |
Is compensated whether or not services are provided |
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Preferred Provider Orgs (PPOs) |
Physical and are paid fees for their services rather than a salary. Group of physicians & hospitals that contract w/ employers/insurers to provide med care services at a reduced fee, unless it of network, for a higher fee. |
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How is a PPO different from a HMO? |
1. Don’t provide care on a prepaid basis 2. Not required to use physicians/facilities that have contracts w/ PPO 3. Referral for specialist not required |
2 ways |
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Point of Service (POS) |
Combo of HMO & PPO. A different choice can be made depending on the circumstances each time |
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Health Reimbursement Account (HRA) |
Plans that allow employers to set aside funds for reimbursing employees for qualified medical exp |
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Health Savings Accounts (HSA) |
Plans designed to help individuals save for qualified health expenses |
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Flexible Spending Account (FSA) |
Funded by salary reduction and employer contributions with annual maximums and “use it or lose it", tax free and limited amount. |
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High Deductible Health Plans |
Higher annual deductibles & out of pocket limits in exchange for lower premiums |
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Disability Income Insurance |
Replaces lost income in the event of being disabled for longer than 90 days |
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Elimination Period |
Waiting period that is imposed on the insured from the onset of disability until benefit payments commence. Deductible’s measured in days. Longer elimination periods mean lower premium, benefits start on the day after elimination period ends in arrears, but payments start 30 days after. |
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Probationary Period |
Waiting period that does not replace the elimination period but is in addition to it from the start of the policy. Often 10-30 days. Sickness, not accidents. Purpose to reduce adverse selection against the insurer |
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Sickness |
Disease contracted after policy in force for 30 days |
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Business Overhead Expense (BOE) |
Sold to small business owners, to cover their overhead after occurring a disability like rent, equipment, salaries, utilities, etc. Does not reimburse business owner for their salary. Tax deductible policy, benefits tax though |
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What are the two policies that pay accidental death? |
Special Risk Policy (stuff not usually covered) & Limited Risk Policy (Specific things to be covered) |
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Long Term Care Policies |
Provides coverage for at least 1yr in a place other than hospital. Include elimination period that insured must be in nursing home. Guaranteed renewable but premium may increase. |
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Home Convalescent Care |
In the insured’s home under a planned program made by the DR. |
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Respite Care |
Provides relief to the family caregiver |
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COBRA Consolidated Omnibus Budget Reconciliation Act of 1985 |
Employer w/ 20 or more employees to extend group health coverage to terminated employees. 18 months of coverage, within 60 days of separation. |
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Hospital Indemnity |
Provides money while insured is confined to a hospital. Aka, hospital fixed rate policy |
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Limited policy coverage covers what? |
Only expenses incurred form specific diseases or causes |
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What has shorter elimination periods? Short term or long term disability? |
Short term |
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Premiums paid by the insured on individual disability income policies are not tax deductible, but |
Benefits are tax free |
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Covered under accidental death and dismemberment? |
Eyesight and both of the same limb only. Not loss of hearing or 1 limb |
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Is there a deductible on a base plan? |
No |
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Health insurance excludes war, self-inflicted injuries, and what? |
Cosmetic surgeries |
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What is the only policy that may use a relative value schedule? |
Surgical expense policy |
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When does a stop loss feature on a major medical policy apply? |
After the insured first pays the deductible |
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What do LTC policies cover? |
Skilled nursing, intermediate care, and custodial care |
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How long do interim policies cover? |
6 months |
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Cafeteria plan |
Allows insured to choose btwn different plans |
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Why is medical expenses insurance (hospital, surgical, medical)refered to add as first dollar coverage? |
No deductible is required |
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Basic surgical expense |
Policy that pays for the cost of the surgeons services |
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Major medical policies |
Coverage for comprehensive coverage for hospital expenses, catastrophic med expense protection, & benefits for prolonged injury with lifetime benefit limit. |
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What was the main goal of HMO? |
To reduce cost with preventative care by using physicians with a prenegotiated price. |
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What does the fact that HMOs operate on a capitated basis mean? |
HMO recieves a flat rate amount each month attributed to each member |
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True or false: HMO service area does not apply to hospital/emergency care. |
True |
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HSAs are linked to high deductible plans. Those who withdrawal early: |
pay tax & 20% penalty, unless 65, they pay just tax |
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How long is the benefit period for disability? |
1,2,5 yrs until age 65. Longer the benefit, higher the premium |
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Accidental bodily injury |
Damage to the body is unexpected and unintended |
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Presumptive disability |
Disability income policies that specify the conditions that will automatically qualify for full benefits. |
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Why aren't disability income insurance offered at a rate of 100% reimbursement? |
To prevent malingering |
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Does a business have to have the key employees signature on the policy? |
Yes |
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Accidental death/dismemberment policies pay how much for lose of 1 limb/eye |
Max 50%. May have double indemnity which pays twice as much |
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LTC excludes: |
Pre existing, mental diseases except for Alzheimer's, drug use addictions, illness from war/suicide attempts, treatment available from government |
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Associate group insurance: |
Must have 100 people for at least two yr with annual meetings |
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Group health insurance characteristics |
Master contract given to employer with employees receiving certificate of insurance |
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HOw long are short term medical plans? |
1-11 months |
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Critical illness policy |
For heart attacks and stuff, insured money after surviving illness for a while |
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Cancer policies pay when ? |
When insured is diagnosed |
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Dental expense insurance, unlike medical expenses insurance, includes... Is it mandatory? |
Preventative and diagnostic care... Mandatory for those 18 and under |
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