Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/66

Click to flip

66 Cards in this Set

  • Front
  • Back
Morbidity
incidence or probablility of sicknesses or accidets within a given group of people
-Elimination period (waiting period)
-probationary period
-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.
pre-existing conditions
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
gatekeeper concept
primary care physician/gate keeper. if specialist needed, primary care physician must refer.
managed care program
attempts to contain costs by controlling the behavior of participants.

-controlled access of providers
-comprehensive case management
-preventive care
-risk sharing
-high quality care.
extension of benefits
12 months after leaves
Corridor Deductible
once limit of basic contract have been paid, corridor deductible must be paid before heavy medical coverage will pay.
Stop Loss Provision
limit to out of pocket expenses the insured can incur during a poilcy year. after which 100% paid by insurance company
free look period
usually 10 days to look over health policy
AD&D health insurance product
(accidental death and dismemberment)
-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
Uniform policy provisions
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.
common accident provision
only one deductible for family members involved in same accitdetn.
integrated deductible
will cover certain amount up front. $800 int.ded., $1000 charge, person has to make up remaining 200.
co-insurance vs. co-payments
co-insurance:%
co-payments: dollar amount
waiver of premium
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.
principle sum vs. capital sum
principle: death or loss of both limbs/eyes

capital: dismemberment, 1 arm 1 foot (50%)
indemnity (double or triple)
in case of accidents, death must occur within 90 days because of accident. will double or triple benefit.
COBRA
consolidated omnibus budget reconciliation Act or 1985

only applies to group HEALTH insurance
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%
COBRA DISQualifying events
failure to make a premium, another group plan, eligibility for medicare, employer terminates allll group plans
ERISA:
Employee retirement income security act of 1974
employees recieve the pension and other benefits promised by their employers.

encourages employers to provide benefits/retirement plans for employees.
all forms fo health care, life insurance, prepaid legal services, disability insurance are considered
"employee welfare benefit" plans.
Garanteed renewable vs. non cancelable
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.
Noncancelable and guaranteed renewable policy
-continue policy until age 50
-puchased after age 44, minimum of 5 years.
-
a. Service type
b. Indemnity type
c. Self Funding
d. Other
a. Blue cross Blue Shield, HMO's . Benefits paid to technicians: doctors, nurses, etc.(prepaid plans as well)

b.
Group Plan:
-experience rating vs. community rating pricing.
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.
HMO's
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
Indemnity plan
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.
MET:
multiple employer Trust
# of individuals or small groups of individuals who do not qualify for group insurance.

-small companies who get bad rates group together
Non insured Trust
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.
PPO:
preferred provider organization
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.
EPO:
Exclusive Provider Organization
must use specific providers who are paid on a fee-for-service basis.
Association group
(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.
franchise
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.
trusts
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.
(disability) Group Plans:
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)
employer paid premiums on group are tax deductible as buisness expense.
not taxible as income to employee
Hmo ppos and point-of-service
"managed care"
many feel leave subscribers with few optional or individual choices for medical care.
non-occupational vs. occupational.
exclude coverage of claims that arise from job-related accidents. occupational cover both on and off the job.
COB provision
coordination of benefits
avoid duplication fo benefit payments and overinsurance when one is covered under many group health plans

establishes which plan in primary plan
hospital income policy
provides specific amount on a daily, weekly, monthly basis only deteremined by # of days in hospital.
surgical schedule
endorsed surgury on a basic surgical expense coverage contract.
open panel vs. closed panel
facilities choose to treat patients other than under HMO: open paneled

in a closed panel, doctors are considered employees of ppo.
dual choice plan
in network or out network.

difference in fees/ deductibles copayments or coinsurance. less if in network.
grace period time limits
at least
-7 days for weekly policy
-10 days for monthly policy
-31 days for all other types.
corridor
pay first dollar up to certain amount, chill out...then pay larger ammounts if money keeps growing.
family medical leave act 1993
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,
-
probationary period
for those who join group, amt of time before can reap benefits.
Financing and PAtient care (not traditional)
HMO
points used to determine pay out (each point worth X amt)
relative value
how long after loses job will cobra cover?
18 months if involuntarily let go
probationary period
for those who join group, amt of time before can reap benefits.
Financing and PAtient care (not traditional)
HMO
points used to determine pay out (each point worth X amt)
relative value
how long after loses job will cobra cover?
18 months if involuntarily let go
Indemnity hospital expense policy
pays certain amount each day in hospital regardless.
Indemnity hospital expense policy
pays certain amount each day in hospital regardless.
probationary period
for those who join group, amt of time before can reap benefits.
probationary period
for those who join group, amt of time before can reap benefits.
Financing and PAtient care (not traditional)
HMO
points used to determine pay out (each point worth X amt)
relative value
how long after loses job will cobra cover?
18 months if involuntarily let go
Indemnity hospital expense policy
pays certain amount each day in hospital regardless.
Financing and PAtient care (not traditional)
HMO
points used to determine pay out (each point worth X amt)
relative value
how long after loses job will cobra cover?
18 months if involuntarily let go
Indemnity hospital expense policy
pays certain amount each day in hospital regardless.