4/8 Flashcards
Name the four major problems of the US healthcare delivery system.
- Rising healthcare expenditures
- Large number of uninsured in the population
- Considerable waste and inefficiency
- Harmful insurer practices
Each plan under the Affordable Care Act has annual ___ that limit the amount insureds must pay in the form of deductibles, coinsurance, copayments, etc.
Out-of-Pocket Limits
A(n) ___ states that a percentage of the bill in excess of the deductible, which the insured must pay out-of-pocket up to some maximum annual dollar limit.
Coinsurance provision
A(n) ___ is a flat amount the insured must pay for certain benefits, such as an office visit or generic drug.
Copayment
The insured’s total out-of-pocket spending is limited by an annual out-of-pocket limit (aka ___), after which the insurer pays 100% of eligible expenses.
Stop-Loss limit
A(n) ___ is a tax exempt account established exclusively for the purpose of paying qualified medical expenses.
Health Savings Account
___ pays a daily or monthly benefit for medical or custodial care received in a nursing facility, in a hospital, or at home.
Long-term care insurance
Which type of long-term care insurance matches the following description?
- Policies reimburse for actual charges up to a daily limit
- Consumers have a choice of daily benefits, which range from $50 to $350
- Policies may cover a different amount depending on the type of facility
- Policies may have limits on the total amount paid over the lifetime of the policy
Expense-incurred (or reimbursement) policies
___ (or per diem policies) are long-term care insurance policies that pay a flat dollar amount per day regardless of actual expenses.
Indemnity policies
A(n) ___ is a waiting period during which time benefits are not paid.
Elimination period
In a qualified long-term care insurance plan, a(n) ___ must be met to receive benefits. Either,
- The insured is unable to perform a certain number of Activities of Daily Life (ADLs), or
- The insured needs substantial supervision to be protected against threats to health and safety because of a severe cognitive impairment
Benefit trigger
Most insurers for LTC policies offer optional ___, which provides benefits if the insured lapses the policy.
Nonforfeiture benefits
Some states have ___ designed to reduce Medicaid expenditures by eliminating or reducing incentives of some people to rely on Medicaid to pay for long-term care.
Long-term Care Partnership Programs
___ provides income payments when the insured is unable to work because of sickness or injury. These income payments are typically limited to 60-70 percent of gross earnings.
Disability-income Insurance
Under the Affordable Care Act, ___ are paid out by insurance companies if they don’t follow the minimum medical loss ratio.
Rebates
___ means that you can perform some by not all of the duties of your occupation.
Partial disability
___ applies when you are gainfully employed and not totally disabled but, solely because of sickness or injury, your loss of income is at least 15 percent of your prior income.
Residual Disability
A(n) ___ benefit is paid to an insured whose earned income is reduced because of an accident or sickness.
pro rata disability
In a disability-income insurance policy, the ___ is the length of time that disability payments are payable after the elimination period is met.
Benefit period
Most disability-income insurance policies automatically include a ___, which means that if the insured is totally disabled for 90 days, future premiums will be waived as long as the insured remains disabled.
Waiver-of-Premium Provision
In disability-income insurance policies, under an optional ___, the insurer periodically adjusts benefits for increases in the cost of living.
Cost-of-Living Rider
In disability-income insurance policies, an optional ___ pays an aditional amount if the policyholder is turned down for SS disability benefits.
Social Security Rider
In disability-income insurance, an optional ___ refunds part or all of the premiums if the policyholder’s claim experience is favorable.
Return of Premiums Rider
A(n) ___ health insurance policy is one in which the insurer guarantees to renew the policy at each anniversary date.
Guaranteed Renewable
Under a(n) ___ health insurance policy, the insurer cannot change, cancel, or refuse to renew the policy as long as premiums are paid on time.
Noncancellable
Under a(n) ___ health insurance policy, the policyholder can renew the policy until a specified age.
Conditionally Renewable
The ___ states that after the health insurance policy has been in force for two years, the insurer cannot void the policy or deny a claim on the basis of misstatements in the applications, except for fraudulent misstatements.
Time Limit on Certain Defenses
In health insurance, the grace period is a(n) ___-day period after the premium due date to pay an overdue premium.
31
In health insurance, the Notice of Claim provision states that the insured must give written notice to the insurer within _ days after a covered loss occurs.
20
In health insurance, the Claims Forms provision states that the insurer is required to send the insured a claim form within _ days after notice is received.
15
In health insurance, the Proof-of-Loss provision states that the insured must send written proof of loss to the insurer within _ days after a covered loss occurs.
90
In health insurance, the ___ provision states that the insurer must pay all claims immediately after receiving proof of loss.
Time of Payment of Claims
In health insurance, the ___ provision gives the insurer the right to examine the insured at its own expense when a claim is pending.
Physical Exam and Autopsy
In health insurance, the Legal Action provision requires the insured to wait at least _ days after proof of loss is submitted before legal action can be brought against the insurer.
60
