Health Insurance

Front 1

What are the two major causes of peril in health insurance

Back 1

sickness
accident

Front 2

an unforeseen and uninteded injury that resulted from an accident rather than a sickness

Back 2

accidental bodily injury

Front 3

loss of income caused by accident or sickness casuing an insured the inability to work is covered under what policy

Back 3

disability income policy

Front 4

policy that covers expenses incurred from an accident or sickness such as physician and hospital expenses

Back 4

medical insurance

Front 5

Expenses paid directly to the insured and the insured would be responsible for paying the medical expense

Back 5

reimbursement

Front 6

form of medical insurance that covers the treatment,care and prevention of dental disease and injury to insured's teeth

Back 6

dental insurance

Front 7

It provides benefits for medically necessary services one receives in a nursing home or own home

Back 7

long-term care policy

Front 8

two separate types of insurance included in the generic term health insurance

Back 8

-coverage for expenses related to health care
-payments for loss of income

Front 9

health insurance policy that is designed to provide periodic payments when an insured is unable to work

Back 9

disability income insurance

Front 10

this insurance provides health coverage for small groups whose numbers are too small to qualify for true group insurance

Back 10

franchise insurance

Front 11

what 2 ways does franchise insurance differ from group insurance

Back 11

-individual policies issued
-individual underwriting

Front 12

which plan only covers specific accidents or diseases.

Back 12

limited health insurance

Front 13

which plan covers all sickness or accidents that are not specifically excluded

Back 13

comprehensive health insurance plan

Front 14

if an insurer is issuing a policy that has limited benefits what must appear on the first page of the policy

Back 14

"THIS IS A LIMITED POLICY"

Front 15

7 types of limited policies

Back 15

-accident only
-AD&D
-travel accident
-specified dread disease
-hospital indemnity income
-credit disability
-blanket insurance

Front 16

the face amount for accidential death is termed

Back 16

principal

Front 17

the amount paid for loss of limb or sight under AD&D policy is called

Back 17

capital (percentage) amount

Front 18

this policy provides a specific amount on a daily, weekly or monthly basis while the insured is confined to hospital

Back 18

hospital indemnity(income)

Front 19

this policy covers members of a particular group when they are participating in a particular activity

Back 19

blanket insurance

Front 20

conditions for which the insured has received diagnosis, advice, care or treatment during the last 6 months prior to application

Back 20

pre-existing condition

Front 21

7 common exclusions from health coverage

Back 21

-pre-exsisting condition
-self-inflicted injury
-war or act of war
-elective cosmetic surgery
-conditions covered by workmans compensation
-goverment plans
-participation in criminal activity

Front 22

this document must be provided to applicant at time of application or upon delivery of the policy, it provides full and fair disclosure to the applicant

Back 22

outline of coverage

Front 23

5 situations an insurance company or agent can disclose personal or privileged information.

Back 23

-written authorization
-info provided to insurance regulatory or law enforment
-audit
-group policyholder for reporting claims
-lien holder

Front 24

this is given to all applicants for health insurance coverage that informs applicant that credit report will be ordered

Back 24

notice to the applicant

Front 25

when underwriting health insurance policies the prime considerations are

Back 25

-age
-gender
-occupation
-physical condition
-avocations
-moral and morale hazards
-financial status of applicant

Front 26

4 classifications of underwriting for health insurance

Back 26

-preferred
-standard
-substandard
-decline

Front 27

how many days is the probationary or waiting period on a health insurance policy after the effective date for which sickness is not covered

Back 27

15 to 30 days

Front 28

if an agent engages in misrepresentation during the replacement of health insurance what can happen

Back 28

--exposed to errors and omissions liability
--have license suspended or revoked

Front 29

when replacing group health insurance, what happens to ongoing claims

Back 29

they must be paid under the new policy, eliminating preexisting conditions

Front 30

this law established standard provisions that are to be included in all individual health insurance policies

Back 30

Uniform indiviual accident and sickness policy provision law

Front 31

any changes on a policy must be authorized by who

Back 31

executive officer of the company

Front 32

what provision states that no statement or misstatement (except fraudulent misstatements) in a life application at time of issue can be used to deny a claim after two years

Back 32

time limit on certain defenses provision

Front 33

unlike life insurance policies, health insurance fraudulent misstatements can be contested at any time unless

Back 33

policy is guaranteed renewable

Front 34

grace period for
weekly
monthly
all others

Back 34

7 days
10 days
31 days

Front 35

if a policy becomes lapsed, reinstatement is automatic when what happens

Back 35

company or representative accepts the premuim payment and does not require a reinstatement application

Front 36

coverage is automatically reinstated if not refused within how many days

Back 36

45 days from the date the conditional receipt was issued

Front 37

on a lapsed policy that has been reinstated how soon will accident and sickness be covered

Back 37

accident immediately
sickness after 10 days

Front 38

time period for legal action against insurance company

Back 38

must wait 60 days after proof of loss and no later than 2 or 3 years

Front 39

the insuring agreement or clause that is located on the first page of the policy and is a general statement that identifies what 3 things

Back 39

-insured
-insurance company
-kind of loss covered

Front 40

for diability income insurance the policy will be renewed beyond age 65 if what

Back 40

insured can provide evidence that he is still working full time

Front 41

medicare and long term care polices are written as ----------and can not be cancelled at age ------

Back 41

guaranteed renewable
65 years old

Front 42

under a conditionally renewable health policy can contract be terminate ____ why? and the amount of premiums can do what?

Back 42

-yes,insurer can terminate for certain conditions that are stipulated
-premiums may increase

Front 43

under what option can an insurer cancel the policy for any reason

Back 43

renewable at option of insurer

Front 44

what type of health insurance is for a specified period of time and is not renewable

Back 44

term health policy

Front 45

disability income insurance is subject to a time deductible called

Back 45

elimination period

Front 46

disability income benefits are limited to what

Back 46

percentage of earned income

Front 47

which disability policy provision provides benefits when the insured because of sickness or injury is unable to perform his own occupation

Back 47

own occupation

Front 48

which disability policy provision will only provide benefits when the insured is unable to perform any occupation

Back 48

any occupation

Front 49

4 requirements to receive disability benefits

Back 49

-inability to perform duties
-pure loss of income
-presumptive disability
-be under a physici
ans care

Front 50

disability policy that replace a certain percentage of the insured's pure loss of income (70-80%) for covered sickness or injury with lower premiums than traditional disability because they take in consideration other sources of income (other disability policies, workmans comp)

Back 50

income replacement contract

Front 51

provision in disability policy that specifies the conditions that will automatically qualify the insured for full benefits
Ex. loss of limb

Back 51

presumptive disability

Front 52

if an individual disability policy is paid for by the individual how are premiums and benefits treated for tax purposes

Back 52

premiums are made with after tax dollars benefits received tax free

Front 53

after receiving disability benefits how long is the elimination period for
one year or less?
more than 1 year less than 2? all others?

Back 53

90 days
180 days
365 days

Front 54

which disability protects the family from ecomonic loss caused by total disability of wage earner

Back 54

basic total disability plan

Front 55

a waiting period that is imposed on the insured from the onset of disability until benefit payments commence?
periods range from____

Back 55

elimination period
30 to 180

Front 56

refers to the length of time over which the monthly disabiltiy benefit payments will last for each disability
after the elimination period has been satisfied

Back 56

benefit period

Front 57

benefit periods can range from-
benefits payments are not retroactive back to elimination period
--longer the benefit period higher the premium

Back 57

1, 2, 5, and to age 65

Front 58

injury is defined using either the

Back 58

accidental bodily injury or accidental means

Front 59

injury that means the damage to the body is unexpected and unintended

Back 59

accidental bodily injury

Front 60

injury that means the cause of the accident must be unexpected and unintended

Back 60

accidental means

Front 61

which injury definition will provide a broader coverage

Back 61

accidental bodily injury

Front 62

a sickness or disease must be contracted how long after the policy has been in force

Back 62

at least 30 days

Front 63

disability provision that specifies the period of time during which the recurrence of an injury or illness will be considered as a continuation of a prior period of disability

Back 63

recurrent disability

Front 64

a provision that extends benefits for the lifetime of the insured if the disability is caused by injury as opposed to sickness

Back 64

lifetime extension rider

Front 65

the benefit that allows the insured, when disabled to forego paying the premiums after a specific number of days has lapsed. after waiting period individual will receive a refund of premiums paid out during the waiting period

Back 65

waiver of premium

Front 66

the benefit that will pay the amount that social security would pay, provided for 1 year

Back 66

additional monthly benefit

Front 67

disabiltiy insurance can be written on what two basis

Back 67

occupational or nonoccupational

Front 68

this basis provides benefits for disabilites resulting from accidents or sickness that occur on or off the job

Back 68

occupational coverage

Front 69

this basis provides benefits for disabilities that result from accidents or sickness occurring off the job

Back 69

nonoccupational coverage

Front 70

this disability is often defined as the inability to perform on or more of the regular duties of one's own occupation or the inability to work full time

Back 70

partial disability benefit

Front 71

the partial disability benefit is typically what percentage of total disability benefit

Back 71

50%

Front 72

the type of disability income policy that provides benfits for loss of income when a person returns to work after a total disability but is still not able to work as long or at the same level

Back 72

residual disability benefit

Front 73

this rider allows an insured to increase benefits level to a specific predetermined amount at certain times or on certain occasions without proof of insurability

Back 73

future increase option rider or guaranteed insurability option

Front 74

under group disability insurance the premiums paid for by the employers are considered what as far as taxes? and the benefits received are taxed or not

Back 74

the premium is deductible to employer and benefits are taxable

Front 75

short term group plans and individual plansprovide maximum benefit period for

Back 75

group 13-26 weeks
individual 6 months to 2 yrs

Front 76

business disability insurance

Back 76

-key person
-buy-sell
-business overhead expense policy
-disability reducing term

Front 77

type of policy that is sold to small business owners who must continue to meet overhead expenses such as rent, utilites, employee salaries

Back 77

business overhead expense policy

Front 78

how are the taxes handled for the premiums and benefits paid on the business overhead expense policy

Back 78

premiums tax deductible
benefits taxed

Front 79

defined as the inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment that has lasted or is expected to last 12 months or result in early death

Back 79

disability under Social Security

Front 80

how long is the elimination period for Social security disability

Back 80

5 months, payments beginning the 6 month and are no retroactive

Front 81

these benefits are payable when a worker is injured by a work related injury regardless of fault or negligence

Back 81

workers compensation benefits

Front 82

workers compensation law provides four types of benefits

Back 82

-medical benefits
-income benefits
-death benefits
-rehabilitation benefits

Front 83

which health policy was designed to provide protection against catastrophic loss

Back 83

major medical

Front 84

major medical expense contracts are characterized by 4 things

Back 84

-high maximum limits
-blanket coverage
-co-insurance
-deductible

Front 85

4 things that affect the major medical policy premium amount

Back 85

-diductible
-coinsurance percentage
-stop-loss
-maximum amount of benefit

Front 86

once the deductible has been met, the insured and the insurance company share the expenses and this is called ------and looks like

Back 86

coinsurance 90/10 80/20

Front 87

the amount the insured pays out of pocket during the year

Back 87

stop loss amount

Front 88

when the insured's out of pocket expenses reach the stop-loss how much does the insurance company pay

Back 88

100% of eligible expenses for the remainder of the year

Front 89

the out of pocket expenses that qualify for the stop loss would be the insured's portion of what

Back 89

coinsurance and may or may not include the deductible

Front 90

major medical plans have a high maximum benefit which is

Back 90

a lifetime maximum

Front 91

provides benefits in the form of services rather than in the form of reimbursement for the services of the physician or hospital

Back 91

HMO health maintenance organization

Front 92

HMO concept is unique in that the HMO provides both the

Back 92

financing and patient care

Front 93

another name for primary care physician

Back 93

gatekeeper

Front 94

HMO provides inpatient hospital care , in or outof service area for how many days and for mental or drug or alcohol

Back 94

90 days per year for treatment of injury or illness
30 days

Front 95

under what system is the physicians paid fees for their services rather than a salary

Back 95

preferred provider organizations (PPOs)

Front 96

when a medical care giver contracts with a health organization to provide services to its members, but retains the right to treat patients who are not members is referred to as

Back 96

open panel

Front 97

in a closed panel the doctors are considered

Back 97

employees of the HMO

Front 98

this plan is a combination of HMO and PPa plans

Back 98

Point-of-service (POS)

Front 99

under which plan can an employee choice a different plan every time a need arises for medical services

Back 99

point of service

Front 100

under what provision can the physician submit the claim information prior to providing treatment to know in advance if procedure is covered and at what rate

Back 100

prospective review or precertification provision

Front 101

pa mandated benefits 12

Back 101

postpartum coverage
routine pap smears
treatment for alcoho abuse
mental illness
annual gyn exams
cancer therapy
mamogram
childhood immunizations
depedent child age
coverage of adopted child
newborn coverage
physical/mental handicapped child

Front 102

dependent child age limit

Back 102

children and stepchildre must be resident of household and under age 19 unless handicapped

Front 103

HIPAA stands for

Back 103

health insurance portability and accountability act

Front 104

when a person leaves employment they will be issued what that will show creditable coverage for the number of months they were covered

Back 104

certificate of creditable coverage

Front 105

an employer funded account linked to a high deductible medical insurance plan for groups of 50 or less

Back 105

medical savings account(MSA)

Front 106

6 underwriting criteria that are factors in group health insurance are

Back 106

-certifcates issued with no underwriting
-premiums ae determined by age, sex and occupation of group
-group formed for a reason other than to purchase insur
-participation levels 75%contributory, 100%noncontributory
-flow of new members through group
-everyone has the same benefits

Front 107

group health plan eligibility requirements

Back 107

work 30 hours
have served from on to three months of employment

Front 108

dependent eligibility

Back 108

-spouse
-child under 19
-unmarried children 19-23 full time students
-unmarried children over 19 handicapped or mentally

Front 109

this provision found only in group health ins. is to avoid duplication of benefit payments and over insurance when covered under more than one group plan

Back 109

coordination of benefits provision

Front 110

under the coordination of benefits provision how are married couples handled

Back 110

the person's own group coverage will be considered primary for them

Front 111

under the coordination of benefits provision how are dependent children handled

Back 111

--under the gender rule father's coverage is primary
--under the birthday rule the coverage of the parent whose birthday is first in the year

Front 112

if the parents are divorced or separated whose insurance is primary

Back 112

the parent who has custody

Front 113

this act requires any employer with 20 or more employees to extend group insurance to terminated employees and their families up to 36 months after qualifying event

Back 113

COBRA consolidated omnibus budget reconciliation

Front 114

the termination of employment for reasons other than misconduct, death or divorce

Back 114

qualifying event

Front 115

the terminated employee has how long to exercise extension of benefits under COBRA

Back 115

60 days of separation of employment

Front 116

what option allows a terminated employee to convert their group to individual ins. without evidence of insurability

Back 116

conversion privilege

Front 117

all forms of health care, life insurance, prepaid legal services, and disability insurance are considered what kind of benefit plans

Back 117

employee welfare benefit plans

Front 118

this care means treatments, which restore functional use to natural teeth such as fillings or crowns

Back 118

restorative

Front 119

care that means operative treatment of the mouth such as extractions or surgical

Back 119

oral surgery

Front 120

means treatment of the dental pulp within natural teeth such as root canal

Back 120

endodontics

Front 121

means the treatment of the surrounding and supporting tissue of the teeth

Back 121

periodontics

Front 122

means the replacement of missing teeth with artificial devices like bridgework or dentures

Back 122

prosthodontics

Front 123

means treatment of natural teeth to prevent or correct dental anomalies with braces

Back 123

orthodontics

Front 124

there are three types of dental plans

Back 124

-scheduled or basic plan
-comprehensive or nonscheduled plan
-combination of both

Front 125

this plan pay benefits from a list of procedures up to the amount shown in the schedule

Back 125

scheduled or basic

Front 126

this plan benefits are paid on a reasonable and customary basis and are subject to deductibles or coins.

Back 126

nonscheduled or comprehensive plan

Front 127

under the nonscheduled plan services are divided into three broad benefit categories

Back 127

-diagnostic/preventive
-basic
-major

Front 128

under basic services such as fillings, oral surgery, periodontics and endodontics may have a deductible or pay what percent

Back 128

80%

Front 129

under major services like crowns and orthodontics could have either a large deductible or pay what percent

Back 129

50%

Front 130

exclusions under a dental plan

Back 130

-cosmetic surgery
-replacement of lost dentures
-duplicate dentures

Front 131

limitations on dental
routine exams and cleaning-
full mouth x-ray-
replacement of dentures-

Back 131

-once every 6 months
-once every 2 to 3 years
-once every 5 years

Front 132

a federal medical expense insurance program for people 65 and older even if the work

Back 132

medicare

Front 133

medicare benefits are also available to anyone, regardless of age who has

Back 133

-received social securtiy disability income benefits for 2 years
-chronic kidney disease

Front 134

who amdinister medicare

Back 134

the health care financing adminstration

Front 135

mdeicare is made up of two parts
part A and part B what are they

Back 135

-part A hospital ins.
-part B medical ins.

Front 136

how is part A funded

Back 136

through a portion of the payroll tax (FICA)

Front 137

how is part B funded

Back 137

is financed from monthly premiums paid by insureds and general revenues of the federal goverment

Front 138

what does Part A cover

Back 138

-inpatient hospital care
-nursing home
-home health care
-hospice care

Front 139

when is a person eligible for medicare Part A

Back 139

the first day of the month that the individual turns 65

Front 140

who qualifies for Medicare Part A

Back 140

-65 or over qualified for SS or Railroad retirement
-65 or over entitled to SS benefit based upon spouse's work record and spouse is 62
-entitled to SS disabiltiy benefits for 24 months
-has end stage renal disease

Front 141

how do you enroll in part A

Back 141

automatic for individuals eligible for SS

Front 142

how do you enroll in part B

Back 142

when you become eligible for part A you are told you will get and have to pay for Part B, if declined you must wait until the next general enrollment period-jan 1 to mar 31

Front 143

the amount a physician or supplier actually bills for a particular service or supply

Back 143

actual charge

Front 144

the amount Medicare determins to be reasonable for a service that is covered under Part B

Back 144

approved amount

Front 145

the physician of a medical supplier agrees to accet the medicare approved amount

Back 145

assignment

Front 146

the portion of medicare's approved amount that the beneficary is responsible for paying

Back 146

coinsurance

Front 147

the aount of expense a beneficiary must first incur before medicare begins paymnet of coverd services

Back 147

deductible

Front 148

the difference between the medicare approved amount for a service and actual charge

Back 148

excess charge

Front 149

the maximum amount a physician may charge a medicaare beneficiary for a covered service if the physician does not accept assignment

Back 149

limiting charge

Front 150

organizations that process inpatient and outpatient claims on individuals by hospitals, nursing homes

Back 150

intermediaries

Front 151

organizations that process claims that are submitted by doctors and suppliers under medicare

Back 151

carriers

Front 152

groups of practicing doctors and other health care professionals who are paid by the goverment to review the care given to medicare patients

Back 152

pee review organization

Front 153

care that is provided at an ambulatory center. these are surgical ervices performed at a center that does not require a hospital stay

Back 153

ambulatory surgical services

Front 154

provides a pap smear to screen for cervical cancer one every three year

Back 154

pap smear screening

Front 155

medial equipment such as oxygen equipment, wheel chars that a doctor prescribes

Back 155

durable medical equipment

Front 156

what is medicare part C

Back 156

medicare + choice
medicare provided by an approve health maintenance organization or preferred provider organization

Front 157

medicare supplement plans offered by private insurance that is designed to fill the gap in coverage attributed to deductibles, co-pyaments and benefit periods

Back 157

medigap

Front 158

if replacement is involved , the insurance company or agent must furnish the applicant with this before issuing or delivering the policy

Back 158

notice regarding replacement

Front 159

notice regarding replacement informs the applicant of a free look provision of how many days

Back 159

30 days

Front 160

a federal and state funded program for those whose income and resources are insufficient to meet the cost of necessary medical care

Back 160

medicaid

Front 161

a person qualifies for medicaid (which reimburses for nursing home costs) by passing certain income and asset limitation tests known as

Back 161

means test

Front 162

under medicaid certain assets are not considered in the means test and are referred to as

Back 162

non countable assets

Front 163

non countable assets include what:

Back 163

-primary residence
-one car
-wedding ring
-and certain life insurance cash values

Front 164

if an asset is not considered non countable under medicaid it is referred to as

Back 164

countable asset

Front 165

this policy provide coverage for individuals who are no longer able to live an independent lifestyle and require living assistance at home or nursing home facility

Back 165

long-term care policies

Front 166

three levels of care in a lon-term care policy

Back 166

-skilled nursing care
-intermediate care
-custodial care

Front 167

in addition to levels of care long-term care may provide coverage for

Back 167

-home health care
-adult day care
-hospice care
-respite care

Front 168

care that is occasional nursing and rehabilitative care provided by medical personnel in an institutional setting or alternative setting

Back 168

intermediate care

Front 169

care for meeting person needs and under a doctor's order such as assistance in eating, dressing,and bathing with care provided home or nursing home

Back 169

custodial care

Front 170

care provided in one's home and could include occasional visits by a nurse

Back 170

home health care

Front 171

care that is designed to provide relief to the family care giver

Back 171

respite care

Front 172

elimination period for long-term care

Back 172

30 days or more in which insured must be confined in a nursing home

Front 173

LTC policies specify a daily amount such as ---
are guaranteed renewable but premiums can increase

Back 173

$50 to $200 per day

Front 174

a nonforfeiture benefit of long term care

Back 174

return of premium

Front 175

return of premium happens when

Back 175

-insured dies
-policy lapsed
a percentage of premium paid is returned

Front 176

Pa regulations and required provisions

Back 176

-outline of coverage
-right to free look
-pre-existing conditions
-conversion from group
-required disclosure
-inflation
-replacement
-shopper's guide

Front 177

a ltc policy can not be issued without insurer receiving a written designation of one person, in addition to the applicant who is to receive notice of lapse or termination

Back 177

unintentional lapse provision