Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
36 Cards in this Set
- Front
- Back
- 3rd side (hint)
Morbidity |
The probability of sickness or accidents within a population; principal factors: age; sex; income |
|
|
Home Health Care Providers |
Services provided in home of patient who does not need institutional care, but needs nursing is special outpatient services |
|
|
Urgent Care |
Provides prompt medical attention without appointment in a non-emergency situation |
|
|
Surgicenters |
Perform surgical services on outpatient basis where patient does NOT have to remain overnight |
|
|
Health Premium Components |
Premium = Morbidity Cost - Interest + Expenses |
P = MIX |
|
Cost Sharing Devices |
Mechanisms for making the insured share in some of the costs of their health care with the insurer |
|
|
Deductible |
Specified dollar amount insured must pay before any benefits will be paid under a health policy |
|
|
Annual Deductible |
Must be satisfied only once each calendar year |
|
|
Per Occurrence (Per Cause) |
Deductible that must be met for each separate illness or accident before benefits are payable (typically found in major medical policies) |
|
|
Individual Deductible |
Annual deductible that must be satisfied for each individual under the same policy |
|
|
Family Deductible |
An annual deductible satisfied when two or more individual deductibles are satisfied under a family policy |
|
|
Copayment |
Specified dollar amount insured must pay each time a covered service is received |
|
|
Coinsurance |
Percentage participation between insured and insurer for covered expenses (after deductible satisfied) ; 80/20 70/30 60/40 50/50 |
|
|
Common Accident Provison |
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 |
|
|
Carryover Provision |
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 |
|
|
Stop-Loss Provision |
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 |
|
|
Pre-Existing Condition |
A condition for which an applicant has sought medical advice, diagnosis or treatment within 6 months before the date of the application. |
|
|
Accident |
Unforeseen/unintentional injury |
|
|
Sickness |
Disease or illness |
|
|
Illness Waiver |
Excludes coverage for an illness that occurs within 30 days of the policy's effective date |
|
|
Free-Look Period |
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 |
|
|
Uniform Policy Provisions |
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 |
|
|
Grace Period (Disability) |
Provision that continues coverage under policy for a specified number of days AFTER premium due date when premium is NOT paid |
|
|
Reinstatement Provision |
Spells out requirements that must be satisfied for insurer to consider reinstating a lapsed policy |
|
|
Notice of Claim |
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 |
|
|
Cancelable Renewability Provision |
Can be cancelled anytime without notice |
|
|
Conditionally Renewable |
Can be non-renewed under certain conditions; premium can be increased by class |
|
|
Guaranteed Renewable |
Cannot be cancelled prior to specified age; premium can be increased (by class) |
|
|
Noncancellable |
Cannot be canceled; premium cannot be increased (by class) |
|
|
Group Health |
Employee receives certificate of insurance/employer owns & controls; master policyowner |
|
|
Coordination of Benefits Provision |
Provision that prevents coverage duplication and overinsurance when individual is covered under more than one group health insurance plan |
|
|
Conversion Provision |
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 |
|
|
Extension of Benefits |
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 |
|
|
No Loss/No Gain Provision (Take Over Benefits) |
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 |
|
|
Exclusions & Limitations |
-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 |
|
|
Blanket Health Insurance |
A form of group insurance issued to an organization that insures the members of that organization (e.g. students in school or college) |
|