Health And Disability Insurance

Front 1

Morbidity

Back 1

incidence or probablility of sicknesses or accidets within a given group of people

Front 2

-Elimination period (waiting period)
-probationary period

Back 2

-deductibile that is commonly found in disability income policies. period fo ays which must expire after the onset of an illness or occurrence of an accident before benefits will be payable. longer elimination period, lower the cost of coverge.

probationary:period fo time before COVERAGE goes into effect

elimination period begins on effective date of policy and lasts 5 months. 6th month can recieve benefits for disability.

Front 3

pre-existing conditions

Back 3

treated condition within 6 months
-group plans impose a 12 month waiting period before pre-existing conditions can be covere (18 month for if late enrollee)
-no appblied in case of newborns, adopted children, pregeers

after 2 year time period, pre-existing conditions will be covered, unless excluded in impairment rider

Front 4

gatekeeper concept

Back 4

primary care physician/gate keeper. if specialist needed, primary care physician must refer.

Front 5

managed care program

Back 5

attempts to contain costs by controlling the behavior of participants.

-controlled access of providers
-comprehensive case management
-preventive care
-risk sharing
-high quality care.

Front 6

extension of benefits

Back 6

12 months after leaves

Front 7

Corridor Deductible

Back 7

once limit of basic contract have been paid, corridor deductible must be paid before heavy medical coverage will pay.

Front 8

Stop Loss Provision

Back 8

limit to out of pocket expenses the insured can incur during a poilcy year. after which 100% paid by insurance company

Front 9

free look period

Back 9

usually 10 days to look over health policy

Front 10

AD&D health insurance product
(accidental death and dismemberment)

Back 10

-benefits found as riders to individ//group life insurane contracts.
-AD&D pay principle sum in the event of accidental death. The same policy will pay the capital sum in the event of dismemberment (50%) something

Front 11

Uniform policy provisions

Back 11

NAIC law that establishes uniform policy terms, provisions, and standards for health insurance policies that cover loss resulting from sickness, bodily injury, or death by accident or both.

Front 12

common accident provision

Back 12

only one deductible for family members involved in same accitdetn.

Front 13

integrated deductible

Back 13

will cover certain amount up front. $800 int.ded., $1000 charge, person has to make up remaining 200.

Front 14

co-insurance vs. co-payments

Back 14

co-insurance:%
co-payments: dollar amount

Front 15

waiver of premium

Back 15

in the event of permanent and total disability, premiums will be waived for the duration of the disability. to qualify, must be disabled for specific period of time 3-6 months. any premiums paid will be refunded, as long as the insured becomes disabled prior to age 5 the premiums will continue to be waived for the duration of the disability.

Front 16

principle sum vs. capital sum

Back 16

principle: death or loss of both limbs/eyes

capital: dismemberment, 1 arm 1 foot (50%)

Front 17

indemnity (double or triple)

Back 17

in case of accidents, death must occur within 90 days because of accident. will double or triple benefit.

Front 18

COBRA
consolidated omnibus budget reconciliation Act or 1985

only applies to group HEALTH insurance

Back 18

any amployer w/ 20 or more employees to extend group health coverage to terminated employees for up to a period of 36 months after a qualifying event.
QUALIFYING EVENT: termination other than misconduct, death, and or divorce.

death of the employee, divorce or legal seperateion, 36 months for dependants.

premium for terminated can not exceed 102%

Front 19

COBRA DISQualifying events

Back 19

failure to make a premium, another group plan, eligibility for medicare, employer terminates allll group plans

Front 20

ERISA:
Employee retirement income security act of 1974

Back 20

employees recieve the pension and other benefits promised by their employers.

encourages employers to provide benefits/retirement plans for employees.

Front 21

all forms fo health care, life insurance, prepaid legal services, disability insurance are considered

Back 21

"employee welfare benefit" plans.

Front 22

Garanteed renewable vs. non cancelable

Back 22

renewable: can increase policy premium on policy anniversary date. always renewable (until 65) Insurer may increase premiums on a class basis only and not on an individual policy.

Front 23

Noncancelable and guaranteed renewable policy

Back 23

-continue policy until age 50
-puchased after age 44, minimum of 5 years.
-

Front 24

a. Service type
b. Indemnity type
c. Self Funding
d. Other

Back 24

a. Blue cross Blue Shield, HMO's . Benefits paid to technicians: doctors, nurses, etc.(prepaid plans as well)

b.

Front 25

Group Plan:
-experience rating vs. community rating pricing.

Back 25

Experience rating (rates to be charged) based ont eh overall experience of the group.

(Blues) still use community rating in pricing products for smaller employers and individuals. pool the experience of all groups in all areas and then the setting of an average rate that will be sufficient to support this experience.

Front 26

HMO's

Back 26

1970's-80's increased healthcare costs. manage health care and the associated costs by proviing prepaid care that emphasized spreventitive care.

-operates in service area
-insureds called subscribers
-covers routine doctor visits, BUT doctor/hospital has to have agreement with HMO

Front 27

Indemnity plan

Back 27

pays benefits fro health insurance based on a predetermined rate set for med. services.
-policy will pay fixed amount regardless of type of care
-claim forms are typically completed and submitted by the participant.

Front 28

MET:
multiple employer Trust

Back 28

# of individuals or small groups of individuals who do not qualify for group insurance.

-small companies who get bad rates group together

Front 29

Non insured Trust

Back 29

operate without the services and funds of an insurance company. once the trust fund is established, self-funding. trustee has charge of funds. employer assumes legal responsibility for providing coverage.

Front 30

PPO:
preferred provider organization

Back 30

physicians payed fees rather than salary, but the member ifs encouraged to visit approved member physicians. members can utilize any physician they choose, the PPO may provide 90% for choice physician while only 70% for non approved list.

Front 31

EPO:
Exclusive Provider Organization

Back 31

must use specific providers who are paid on a fee-for-service basis.

Front 32

Association group

Back 32

(alumni or professional) can buy group insurance for members. must have 100+, have a constitution, be organized for other reason than insurance, active for 2 years, by-lawws, hold annual meetings (1).

-trade associations,
-veterans
-customers of large retail chains

may be contributory or noncontributory.

Front 33

franchise

Back 33

small groups. too small to qualify for true group.


-individual policies submitted
-each participant submits own application/medical history.

generally less than individual, but more than group.

Front 34

trusts

Back 34

groups of persons w/wo dependents,

-an employer insuring at least 5 employees, for benefit of persons other than the employer
-labor union, 25+, constitution, bylaws, other than insurance
-similar group w/ permission of commisioner.

Front 35

(disability) Group Plans:

Back 35

usually specify the benefits on % of workers income (disability)
-short term provide max. 13-26 weeks (50-100% income)
-long term 2 years, (60%)
-minimum participation req (usually 30-90 days.
-benefits supp. to benefits recieved under workers comp (which incidentally is required by govt. law)

Front 36

employer paid premiums on group are tax deductible as buisness expense.

Back 36

not taxible as income to employee

Front 37

Hmo ppos and point-of-service

Back 37

"managed care"
many feel leave subscribers with few optional or individual choices for medical care.

Front 38

non-occupational vs. occupational.

Back 38

exclude coverage of claims that arise from job-related accidents. occupational cover both on and off the job.

Front 39

COB provision
coordination of benefits

Back 39

avoid duplication fo benefit payments and overinsurance when one is covered under many group health plans

establishes which plan in primary plan

Front 40

hospital income policy

Back 40

provides specific amount on a daily, weekly, monthly basis only deteremined by # of days in hospital.

Front 41

surgical schedule

Back 41

endorsed surgury on a basic surgical expense coverage contract.

Front 42

open panel vs. closed panel

Back 42

facilities choose to treat patients other than under HMO: open paneled

in a closed panel, doctors are considered employees of ppo.

Front 43

dual choice plan

Back 43

in network or out network.

difference in fees/ deductibles copayments or coinsurance. less if in network.

Front 44

grace period time limits

Back 44

at least
-7 days for weekly policy
-10 days for monthly policy
-31 days for all other types.

Front 45

corridor

Back 45

pay first dollar up to certain amount, chill out...then pay larger ammounts if money keeps growing.

Front 46

family medical leave act 1993

Back 46

eligible employee is entitled to a total of 12 workweeks of leave during any 12-month period for
-birth
-placement in foster/adoption
-in order to are for spouse, son, daughter, parent,
-

Front 47

probationary period

Back 47

for those who join group, amt of time before can reap benefits.

Front 48

Financing and PAtient care (not traditional)

Back 48

HMO

Front 49

points used to determine pay out (each point worth X amt)

Back 49

relative value

Front 50

how long after loses job will cobra cover?

Back 50

18 months if involuntarily let go

Front 51

probationary period

Back 51

for those who join group, amt of time before can reap benefits.

Front 52

Financing and PAtient care (not traditional)

Back 52

HMO

Front 53

points used to determine pay out (each point worth X amt)

Back 53

relative value

Front 54

how long after loses job will cobra cover?

Back 54

18 months if involuntarily let go

Front 55

Indemnity hospital expense policy

Back 55

pays certain amount each day in hospital regardless.

Front 56

Indemnity hospital expense policy

Back 56

pays certain amount each day in hospital regardless.

Front 57

probationary period

Back 57

for those who join group, amt of time before can reap benefits.

Front 58

probationary period

Back 58

for those who join group, amt of time before can reap benefits.

Front 59

Financing and PAtient care (not traditional)

Back 59

HMO

Front 60

points used to determine pay out (each point worth X amt)

Back 60

relative value

Front 61

how long after loses job will cobra cover?

Back 61

18 months if involuntarily let go

Front 62

Indemnity hospital expense policy

Back 62

pays certain amount each day in hospital regardless.

Front 63

Financing and PAtient care (not traditional)

Back 63

HMO

Front 64

points used to determine pay out (each point worth X amt)

Back 64

relative value

Front 65

how long after loses job will cobra cover?

Back 65

18 months if involuntarily let go

Front 66

Indemnity hospital expense policy

Back 66

pays certain amount each day in hospital regardless.