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Spec Hlth Insurance

Basic Medical, Hospital, Surgical Policies cover hospital room & board, lab and xray charges, medicine while in hospital
Major Medical Policies cover comprehensive hospital coverage, catastrophic medical expense, prolonged injury or illness
2 Major Medical Policies 1. Supplemental 2. Comprehensive
HMO (Health Maintenence Organization) preventive care, limited choice of providers, copayments, prepaid basis (MEANING?), Personal Care Provider is gatekeeper, referral to specialist from provider PCP required
PPO (Preferred Provider Organization) contract with groups of physicians and hospitals to provide services at reduced rates, members can use any physicians but are encouraged to and benefit financially by using those in preferred groups
POS (Point of Service Plans) combination of HMO and PPO, employees not locked into one plan, can choose depending on situations as medical care needed
FSA (Flexible Spending Accounts) a special savings plan for health-related expenses, funded by salary reduction (lowering taxable income) and at times employer contributions, has annual maximum, must be used by end date or is lost
HDHP (High Deductible Health Plan) lower premiums (payments), higher deductible, higher out-of-pocket limits *Often coupled with HSA*
HSA (Health Savings Account) special savings plan for health-related expenses, funded by salary reduction (lowering taxable income), lower health premiums, must pay for all med expenses out of this account until out-of-pocket maximum is met or account depleted (then must pay on own)
HRA (Health Reimbursement Account) account created by employers for employees to get reimbursed for qualifying med expenses (DEDUCTIBLES/COINSURANCE OR MORE?), employers receive the tax advantage bc can be deducted as business expense, WHAT ARE LTC POLICIES?
Long-Term Care Insurance coverage for individuals who require living assistance at home or nursing home, protects assets of the individual
Long Term-Care Insurance Policies available as group, individual, and life insurance riders (add-ons), covers living assistance at home or nursing home, covers 12 consecutive months in a setting other than a care unit or hospital, guaranteed renewable (but premiums can go up)
Levels of Care: Skilled Care daily nursing & rehab care provided by medial personnel
Levels of Care: Intermediate Care occasional nurse or rehab care for stable conditions - required less frequently
Levels of. Care: Custodial Care care for a person's activities of daily living provided at home or in a facility
Levels of Care: Home Health Care care provided by a licensed provider in one's home
Levels of Care: Home Convalescent Care care provided in the home by a health care agency or hospital under planned program by physician
Levels of Care: Residential Care care when in retirement community
Levels of Care: Adult Day Care daily care for functionally-impaired adults - less than 24 hours
Group Insurance insurance for a group formed for a purpose other than insurance, requires all members to be covered, doesn't usually require evidence of insurability
Mandatory Provisions: Change of Beneficiary Revocable: policy holder can change his/her beneficiary at any time Irrevocable: change requires consent from beneficiary If not beneficiary, benefits go to deceased estate
Other Provisions / Clauses: Free Look policy can be returned for a refund
Other Provisions / Clauses: Waiver of Premium premium can be waived in the event of permanent or total disability
Owner's Rights The owner controls his/her information and can make changes when needed
ACA (Affordable Care Act): Dependent Children Benefits insurance must be provided to all children until age 26 regardless of marital status or employment), cannot be terminated at 26 if child is dependent on and incapable of self support
COB (Coordination of Benefits) avoid duplicate benefit payments when covered by multiple plans, establishes the primary plan
Occupational Coverage benefits for illness, injury, or disability resulting in accidents or sickness that occur on and off the job
Non-Occupational Coverage benefits only cover claims that occur off the job
Managed Care preventative healthcare guidance that attempts to contain costs by controlling participant behavior
Medicare Basics medical expense insurance that begins at age 65, can be combined with social security (NOT SURE WHAT YOU MEAN BY 2+ YEARS OR PERMANENT KIDNEY FAILURE)
Medicare: Part A hospital insurance - inpatient hospital care, skilled-nursing care, home health care, hospice care
Medicare: Part B optional to all enrolled in Part A, physician services, outpatient hospital services, home health visits, other medical services, a limited number of prescribed drugs, mental health outpatient, yearly wellness visits
Medicare: Part C (Medicare Advantage/formerly Medicare & Choice Plans) optional to all enrolled in Part A and Part B, an enhanced coverage provided by an HMO or PPO
Medicare: Part D prescription drugs
Medicaid insurance for low-income individuals or families of lower income and assets
Social Security: Disability for those with physical or mental impairment that is expected to result in early death or expected to last longer than 12 months, NOT SURE WHAT THE CREDIT REQUIREMENTS MEAN
Medigap private insurance policies to fill gaps in Medicare Plan A: help with coinsurance/copayments, additional hospital costs, hospice coinsurance/copayments
Misrepresentation faking news or media to make something look better than it is
False Information Advertising ADD DETAILS HERE
Rebating special favors or services, advantages of dividends, stocks, bonds, etc
Coercion persuading someone to do something using threats - manipulation requiring a condition, purchase of insurance, purchase from a specific agent
Defamation to say something maliciously to hurt someone
Coinsurance a percentage to be paid by the insured (i.e. insurance pays 20% of the bill and the insured pays 20%)
Deductable a set amount to be paid by the insured (i.e. $20 for a doctor visit)
Impairment or Exclusion Rider eliminating or excluding coverage for a pre-existing condition or impairment, temporary or permanent, no extra charge or premium reduction
Guaranteed Insurability Rider future increase option or guaranteed purchase option, NOT SURE WHAT YOU MEAN BY PURCHASE MORE DISABILITY INCOME COVERAGE WITHOUT EVIDENCE OF INSURABILITY
Claim Procedure *insured must contact insurance company within 20 days *company must supply claim form within 15 days of contact *insured (claimant) must submit proof of loss within 90 days if possible (not to exceed one year) DOUBLE CHECK THIS
Misstatement of Age get benefits that the premium would have paid at correct age IS THIS IF THERE'S A MISTAKE MADE BY THE COMPANY?
Field Underwriting Process: Consideration Insured: payment of premium & representations from application Insurer: promise to pay in event of loss
Field Underwriting Process: Representations statements and answers the insured gives to questions on the application
Field Underwriting Process: Material (??) misrepresentation will cause the contract to fail
Field Underwriting Process: Coverage coverages does not begin until the insurer has approved the application and issued a policy
Field Underwriting Process: Fair Credit Reporting Act ensures records are confidential, accurate, relevant, and properly used
First Dollar Coverage insurance with no initial deductible
Iowa Individual Health Benefit (?) set average premium rates for basic and standard coverages and amount of earned premium and paid losses
Unpaid Premium pay the claim and deduct the unpaid premium
Insurance for pregnancy complications during hospital stay for non-elective C-section (ONLY OR INCLUDING?)
Group Insurance all in group covered and get certificates (POLICIES?)
Medicare Supplement (IS THIS THE NAME?) *standardization of coverage, terms, and benefits *helps the public understand and compare policies *eliminate misleading and confusing provisions *provide full disclosure in the sale of coverages *losses more than 6 months ago ????????? WHAT IS THIS?
Health Rate Determiners *geographic area *family composition *age *tobacco use
Non-cancellable policy
Competent Party
Supplemental Major Medical
Termination or change in employment options
Guaranteed Purchase Option
Formerly called Medicare & Choice Plans Medicare Advantage Plans
Presumptive Disability
Impairment Rider excludes coverage for a specific impairment
A core medicare supplement (Part A) will cover all of the following expenses except Part A Deductibles
What is the primary difference between Medicare Select and Medigap policies? Medicare Select policies contain restricted network provisions (EXPLAIN THIS - NOT SURE WHAT IT MEANS -- DOES IT MEAN THAT THE NETWORK OF PROVIDERS IS RESTRICTED?
Medicare Select
What are the characteristics of group health insurance plans?
Contract of Adhesion
Group Health Plan: Extensions for Dependents
Insuring Clause the first page of the policy that includes a list of losses that will be covered by her insurer
How much does partial disability usually pay? 50%
Group Health Plan: Groups must be for something other than insurance AN ASSOCIATION OF 35 PEOPLE ?? TRUE??
Other Provisions: Relation of Earnings to Insurance Insurers are allowed to limit benefits to an insured's average income over the previous two years -- EXPLAIN -- IF IT CHANGES?
Key Person Disability Income
Taxation of Disability Income Benefits
Created by: cmteske
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