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177 Cards in this Set

  • Front
  • Back
What are the two major causes of peril in health insurance
sickness
accident
an unforeseen and uninteded injury that resulted from an accident rather than a sickness
accidental bodily injury
loss of income caused by accident or sickness casuing an insured the inability to work is covered under what policy
disability income policy
policy that covers expenses incurred from an accident or sickness such as physician and hospital expenses
medical insurance
Expenses paid directly to the insured and the insured would be responsible for paying the medical expense
reimbursement
form of medical insurance that covers the treatment,care and prevention of dental disease and injury to insured's teeth
dental insurance
It provides benefits for medically necessary services one receives in a nursing home or own home
long-term care policy
two separate types of insurance included in the generic term health insurance
-coverage for expenses related to health care
-payments for loss of income
health insurance policy that is designed to provide periodic payments when an insured is unable to work
disability income insurance
this insurance provides health coverage for small groups whose numbers are too small to qualify for true group insurance
franchise insurance
what 2 ways does franchise insurance differ from group insurance
-individual policies issued
-individual underwriting
which plan only covers specific accidents or diseases.
limited health insurance
which plan covers all sickness or accidents that are not specifically excluded
comprehensive health insurance plan
if an insurer is issuing a policy that has limited benefits what must appear on the first page of the policy
"THIS IS A LIMITED POLICY"
7 types of limited policies
-accident only
-AD&D
-travel accident
-specified dread disease
-hospital indemnity income
-credit disability
-blanket insurance
the face amount for accidential death is termed
principal
the amount paid for loss of limb or sight under AD&D policy is called
capital (percentage) amount
this policy provides a specific amount on a daily, weekly or monthly basis while the insured is confined to hospital
hospital indemnity(income)
this policy covers members of a particular group when they are participating in a particular activity
blanket insurance
conditions for which the insured has received diagnosis, advice, care or treatment during the last 6 months prior to application
pre-existing condition
7 common exclusions from health coverage
-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
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
outline of coverage
5 situations an insurance company or agent can disclose personal or privileged information.
-written authorization
-info provided to insurance regulatory or law enforment
-audit
-group policyholder for reporting claims
-lien holder
this is given to all applicants for health insurance coverage that informs applicant that credit report will be ordered
notice to the applicant
when underwriting health insurance policies the prime considerations are
-age
-gender
-occupation
-physical condition
-avocations
-moral and morale hazards
-financial status of applicant
4 classifications of underwriting for health insurance
-preferred
-standard
-substandard
-decline
how many days is the probationary or waiting period on a health insurance policy after the effective date for which sickness is not covered
15 to 30 days
if an agent engages in misrepresentation during the replacement of health insurance what can happen
--exposed to errors and omissions liability
--have license suspended or revoked
when replacing group health insurance, what happens to ongoing claims
they must be paid under the new policy, eliminating preexisting conditions
this law established standard provisions that are to be included in all individual health insurance policies
Uniform indiviual accident and sickness policy provision law
any changes on a policy must be authorized by who
executive officer of the company
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
time limit on certain defenses provision
unlike life insurance policies, health insurance fraudulent misstatements can be contested at any time unless
policy is guaranteed renewable
grace period for
weekly
monthly
all others
7 days
10 days
31 days
if a policy becomes lapsed, reinstatement is automatic when what happens
company or representative accepts the premuim payment and does not require a reinstatement application
coverage is automatically reinstated if not refused within how many days
45 days from the date the conditional receipt was issued
on a lapsed policy that has been reinstated how soon will accident and sickness be covered
accident immediately
sickness after 10 days
time period for legal action against insurance company
must wait 60 days after proof of loss and no later than 2 or 3 years
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
-insured
-insurance company
-kind of loss covered
for diability income insurance the policy will be renewed beyond age 65 if what
insured can provide evidence that he is still working full time
medicare and long term care polices are written as ----------and can not be cancelled at age ------
guaranteed renewable
65 years old
under a conditionally renewable health policy can contract be terminate ____ why? and the amount of premiums can do what?
-yes,insurer can terminate for certain conditions that are stipulated
-premiums may increase
under what option can an insurer cancel the policy for any reason
renewable at option of insurer
what type of health insurance is for a specified period of time and is not renewable
term health policy
disability income insurance is subject to a time deductible called
elimination period
disability income benefits are limited to what
percentage of earned income
which disability policy provision provides benefits when the insured because of sickness or injury is unable to perform his own occupation
own occupation
which disability policy provision will only provide benefits when the insured is unable to perform any occupation
any occupation
4 requirements to receive disability benefits
-inability to perform duties
-pure loss of income
-presumptive disability
-be under a physici
ans care
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)
income replacement contract
provision in disability policy that specifies the conditions that will automatically qualify the insured for full benefits
Ex. loss of limb
presumptive disability
if an individual disability policy is paid for by the individual how are premiums and benefits treated for tax purposes
premiums are made with after tax dollars benefits received tax free
after receiving disability benefits how long is the elimination period for
one year or less?
more than 1 year less than 2? all others?
90 days
180 days
365 days
which disability protects the family from ecomonic loss caused by total disability of wage earner
basic total disability plan
a waiting period that is imposed on the insured from the onset of disability until benefit payments commence?
periods range from____
elimination period
30 to 180
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
benefit period
benefit periods can range from-
benefits payments are not retroactive back to elimination period
--longer the benefit period higher the premium
1, 2, 5, and to age 65
injury is defined using either the
accidental bodily injury or accidental means
injury that means the damage to the body is unexpected and unintended
accidental bodily injury
injury that means the cause of the accident must be unexpected and unintended
accidental means
which injury definition will provide a broader coverage
accidental bodily injury
a sickness or disease must be contracted how long after the policy has been in force
at least 30 days
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
recurrent disability
a provision that extends benefits for the lifetime of the insured if the disability is caused by injury as opposed to sickness
lifetime extension rider
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
waiver of premium
the benefit that will pay the amount that social security would pay, provided for 1 year
additional monthly benefit
disabiltiy insurance can be written on what two basis
occupational or nonoccupational
this basis provides benefits for disabilites resulting from accidents or sickness that occur on or off the job
occupational coverage
this basis provides benefits for disabilities that result from accidents or sickness occurring off the job
nonoccupational coverage
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
partial disability benefit
the partial disability benefit is typically what percentage of total disability benefit
50%
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
residual disability benefit
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
future increase option rider or guaranteed insurability option
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
the premium is deductible to employer and benefits are taxable
short term group plans and individual plansprovide maximum benefit period for
group 13-26 weeks
individual 6 months to 2 yrs
business disability insurance
-key person
-buy-sell
-business overhead expense policy
-disability reducing term
type of policy that is sold to small business owners who must continue to meet overhead expenses such as rent, utilites, employee salaries
business overhead expense policy
how are the taxes handled for the premiums and benefits paid on the business overhead expense policy
premiums tax deductible
benefits taxed
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
disability under Social Security
how long is the elimination period for Social security disability
5 months, payments beginning the 6 month and are no retroactive
these benefits are payable when a worker is injured by a work related injury regardless of fault or negligence
workers compensation benefits
workers compensation law provides four types of benefits
-medical benefits
-income benefits
-death benefits
-rehabilitation benefits
which health policy was designed to provide protection against catastrophic loss
major medical
major medical expense contracts are characterized by 4 things
-high maximum limits
-blanket coverage
-co-insurance
-deductible
4 things that affect the major medical policy premium amount
-diductible
-coinsurance percentage
-stop-loss
-maximum amount of benefit
once the deductible has been met, the insured and the insurance company share the expenses and this is called ------and looks like
coinsurance 90/10 80/20
the amount the insured pays out of pocket during the year
stop loss amount
when the insured's out of pocket expenses reach the stop-loss how much does the insurance company pay
100% of eligible expenses for the remainder of the year
the out of pocket expenses that qualify for the stop loss would be the insured's portion of what
coinsurance and may or may not include the deductible
major medical plans have a high maximum benefit which is
a lifetime maximum
provides benefits in the form of services rather than in the form of reimbursement for the services of the physician or hospital
HMO health maintenance organization
HMO concept is unique in that the HMO provides both the
financing and patient care
another name for primary care physician
gatekeeper
HMO provides inpatient hospital care , in or outof service area for how many days and for mental or drug or alcohol
90 days per year for treatment of injury or illness
30 days
under what system is the physicians paid fees for their services rather than a salary
preferred provider organizations (PPOs)
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
open panel
in a closed panel the doctors are considered
employees of the HMO
this plan is a combination of HMO and PPa plans
Point-of-service (POS)
under which plan can an employee choice a different plan every time a need arises for medical services
point of service
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
prospective review or precertification provision
pa mandated benefits 12
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
dependent child age limit
children and stepchildre must be resident of household and under age 19 unless handicapped
HIPAA stands for
health insurance portability and accountability act
when a person leaves employment they will be issued what that will show creditable coverage for the number of months they were covered
certificate of creditable coverage
an employer funded account linked to a high deductible medical insurance plan for groups of 50 or less
medical savings account(MSA)
6 underwriting criteria that are factors in group health insurance are
-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
group health plan eligibility requirements
work 30 hours
have served from on to three months of employment
dependent eligibility
-spouse
-child under 19
-unmarried children 19-23 full time students
-unmarried children over 19 handicapped or mentally
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
coordination of benefits provision
under the coordination of benefits provision how are married couples handled
the person's own group coverage will be considered primary for them
under the coordination of benefits provision how are dependent children handled
--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
if the parents are divorced or separated whose insurance is primary
the parent who has custody
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
COBRA consolidated omnibus budget reconciliation
the termination of employment for reasons other than misconduct, death or divorce
qualifying event
the terminated employee has how long to exercise extension of benefits under COBRA
60 days of separation of employment
what option allows a terminated employee to convert their group to individual ins. without evidence of insurability
conversion privilege
all forms of health care, life insurance, prepaid legal services, and disability insurance are considered what kind of benefit plans
employee welfare benefit plans
this care means treatments, which restore functional use to natural teeth such as fillings or crowns
restorative
care that means operative treatment of the mouth such as extractions or surgical
oral surgery
means treatment of the dental pulp within natural teeth such as root canal
endodontics
means the treatment of the surrounding and supporting tissue of the teeth
periodontics
means the replacement of missing teeth with artificial devices like bridgework or dentures
prosthodontics
means treatment of natural teeth to prevent or correct dental anomalies with braces
orthodontics
there are three types of dental plans
-scheduled or basic plan
-comprehensive or nonscheduled plan
-combination of both
this plan pay benefits from a list of procedures up to the amount shown in the schedule
scheduled or basic
this plan benefits are paid on a reasonable and customary basis and are subject to deductibles or coins.
nonscheduled or comprehensive plan
under the nonscheduled plan services are divided into three broad benefit categories
-diagnostic/preventive
-basic
-major
under basic services such as fillings, oral surgery, periodontics and endodontics may have a deductible or pay what percent
80%
under major services like crowns and orthodontics could have either a large deductible or pay what percent
50%
exclusions under a dental plan
-cosmetic surgery
-replacement of lost dentures
-duplicate dentures
limitations on dental
routine exams and cleaning-
full mouth x-ray-
replacement of dentures-
-once every 6 months
-once every 2 to 3 years
-once every 5 years
a federal medical expense insurance program for people 65 and older even if the work
medicare
medicare benefits are also available to anyone, regardless of age who has
-received social securtiy disability income benefits for 2 years
-chronic kidney disease
who amdinister medicare
the health care financing adminstration
mdeicare is made up of two parts
part A and part B what are they
-part A hospital ins.
-part B medical ins.
how is part A funded
through a portion of the payroll tax (FICA)
how is part B funded
is financed from monthly premiums paid by insureds and general revenues of the federal goverment
what does Part A cover
-inpatient hospital care
-nursing home
-home health care
-hospice care
when is a person eligible for medicare Part A
the first day of the month that the individual turns 65
who qualifies for Medicare Part A
-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
how do you enroll in part A
automatic for individuals eligible for SS
how do you enroll in part B
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
the amount a physician or supplier actually bills for a particular service or supply
actual charge
the amount Medicare determins to be reasonable for a service that is covered under Part B
approved amount
the physician of a medical supplier agrees to accet the medicare approved amount
assignment
the portion of medicare's approved amount that the beneficary is responsible for paying
coinsurance
the aount of expense a beneficiary must first incur before medicare begins paymnet of coverd services
deductible
the difference between the medicare approved amount for a service and actual charge
excess charge
the maximum amount a physician may charge a medicaare beneficiary for a covered service if the physician does not accept assignment
limiting charge
organizations that process inpatient and outpatient claims on individuals by hospitals, nursing homes
intermediaries
organizations that process claims that are submitted by doctors and suppliers under medicare
carriers
groups of practicing doctors and other health care professionals who are paid by the goverment to review the care given to medicare patients
pee review organization
care that is provided at an ambulatory center. these are surgical ervices performed at a center that does not require a hospital stay
ambulatory surgical services
provides a pap smear to screen for cervical cancer one every three year
pap smear screening
medial equipment such as oxygen equipment, wheel chars that a doctor prescribes
durable medical equipment
what is medicare part C
medicare + choice
medicare provided by an approve health maintenance organization or preferred provider organization
medicare supplement plans offered by private insurance that is designed to fill the gap in coverage attributed to deductibles, co-pyaments and benefit periods
medigap
if replacement is involved , the insurance company or agent must furnish the applicant with this before issuing or delivering the policy
notice regarding replacement
notice regarding replacement informs the applicant of a free look provision of how many days
30 days
a federal and state funded program for those whose income and resources are insufficient to meet the cost of necessary medical care
medicaid
a person qualifies for medicaid (which reimburses for nursing home costs) by passing certain income and asset limitation tests known as
means test
under medicaid certain assets are not considered in the means test and are referred to as
non countable assets
non countable assets include what:
-primary residence
-one car
-wedding ring
-and certain life insurance cash values
if an asset is not considered non countable under medicaid it is referred to as
countable asset
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
long-term care policies
three levels of care in a lon-term care policy
-skilled nursing care
-intermediate care
-custodial care
in addition to levels of care long-term care may provide coverage for
-home health care
-adult day care
-hospice care
-respite care
care that is occasional nursing and rehabilitative care provided by medical personnel in an institutional setting or alternative setting
intermediate care
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
custodial care
care provided in one's home and could include occasional visits by a nurse
home health care
care that is designed to provide relief to the family care giver
respite care
elimination period for long-term care
30 days or more in which insured must be confined in a nursing home
LTC policies specify a daily amount such as ---
are guaranteed renewable but premiums can increase
$50 to $200 per day
a nonforfeiture benefit of long term care
return of premium
return of premium happens when
-insured dies
-policy lapsed
a percentage of premium paid is returned
Pa regulations and required provisions
-outline of coverage
-right to free look
-pre-existing conditions
-conversion from group
-required disclosure
-inflation
-replacement
-shopper's guide
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
unintentional lapse provision