Heath Insurance

Front 1

Morbidity

Back 1

The probability of sickness or accidents within a population; principal factors: age; sex; income

Front 2

Home Health Care Providers

Back 2

Services provided in home of patient who does not need institutional care, but needs nursing is special outpatient services

Front 3

Urgent Care

Back 3

Provides prompt medical attention without appointment in a non-emergency situation

Front 4

Surgicenters

Back 4

Perform surgical services on outpatient basis where patient does NOT have to remain overnight

Front 5

Health Premium Components

Back 5

Premium = Morbidity Cost - Interest + Expenses

Hint 5

P = MIX

Front 6

Cost Sharing Devices

Back 6

Mechanisms for making the insured share in some of the costs of their health care with the insurer

Front 7

Deductible

Back 7

Specified dollar amount insured must pay before any benefits will be paid under a health policy

Front 8

Annual Deductible

Back 8

Must be satisfied only once each calendar year

Front 9

Per Occurrence (Per Cause)

Back 9

Deductible that must be met for each separate illness or accident before benefits are payable (typically found in major medical policies)

Front 10

Individual Deductible

Back 10

Annual deductible that must be satisfied for each individual under the same policy

Front 11

Family Deductible

Back 11

An annual deductible satisfied when two or more individual deductibles are satisfied under a family policy

Front 12

Copayment

Back 12

Specified dollar amount insured must pay each time a covered service is received

Front 13

Coinsurance

Back 13

Percentage participation between insured and insurer for covered expenses (after deductible satisfied) ;

80/20

70/30

60/40

50/50

Front 14

Common Accident Provison

Back 14

When 2 or more insured's under a family health policy are injured in the same accident, only one (1) deductible needs to be satisfied

Front 15

Carryover Provision

Back 15

Provision allowing any deductible paid during the last 3 months of the year to be applied (carried over) to the following year's annual deductible

Front 16

Stop-Loss Provision

Back 16

Provision in policies with coinsurance that says insurer will pay 100% of covered medical expenses once the insured has paid a maximum out-of-pocket amount specified in the policy

Front 17

Pre-Existing Condition

Back 17

A condition for which an applicant has sought medical advice, diagnosis or treatment within 6 months before the date of the application.

Front 18

Accident

Back 18

Unforeseen/unintentional injury

Front 19

Sickness

Back 19

Disease or illness

Front 20

Illness Waiver

Back 20

Excludes coverage for an illness that occurs within 30 days of the policy's effective date

Front 21

Free-Look Period

Back 21

Key required period of time during which a new individual (not group) disability policy can be returned to insurer for any reason and all premiums refunded to the policyowner

Front 22

Uniform Policy Provisions

Back 22

Provisions for individual disability policies put forth by NAIC; insurer may change wording as long as new wording is no less favorable to insured/beneficiary

Front 23

Grace Period (Disability)

Back 23

Provision that continues coverage under policy for a specified number of days AFTER premium due date when premium is NOT paid

Front 24

Reinstatement Provision

Back 24

Spells out requirements that must be satisfied for insurer to consider reinstating a lapsed policy

Front 25

Notice of Claim

Back 25

Written notice of claim most be given to the insurance company w/in 20 days after the occurrence of the event on which the claim is based; for ongoing disability, the insurer has the right to examine insured, at its expense, as often as reasonable to verify the insured's continuing disability

Front 26

Cancelable Renewability Provision

Back 26

Can be cancelled anytime without notice

Front 27

Conditionally Renewable

Back 27

Can be non-renewed under certain conditions; premium can be increased by class

Front 28

Guaranteed Renewable

Back 28

Cannot be cancelled prior to specified age; premium can be increased (by class)

Front 29

Noncancellable

Back 29

Cannot be canceled; premium cannot be increased (by class)

Front 30

Group Health

Back 30

Employee receives certificate of insurance/employer owns & controls; master policyowner

Front 31

Coordination of Benefits Provision

Back 31

Provision that prevents coverage duplication and overinsurance when individual is covered under more than one group health insurance plan

Front 32

Conversion Provision

Back 32

Required provision in group health plans that allows insured to convert (w/o E of I) to individual plan within 31 days after group health coverage terminates

Front 33

Extension of Benefits

Back 33

Provision in group health plan that extends coverage up to 12 months for an employee who is totally disabled at the time employer discontinues coverage

Front 34

No Loss/No Gain Provision (Take Over Benefits)

Back 34

Provision that affords employees coverage for pre-existing conditions under a new group health policy with no waiting period when switching from one group health plan to a new one

Front 35

Exclusions & Limitations

Back 35

-Pre-Existing Conditions

-Elective cosmetic surgery

-Intentionality self-inflicted injuries

-injuries sustained while committing criminal acts

-War and Acts of War

-Worker's compensation losses

-Foreign travel

Front 36

Blanket Health Insurance

Back 36

A form of group insurance issued to an organization that insures the members of that organization (e.g. students in school or college)