Chapter 13: Individual Medical Expense Insurance Flashcards
COBRA
A provision of the consolidated omnibus budget reconciliation act of 1985 that requires group health plans to allow employees and certain beneficiaries to extend their current health insurance coverage at group rates for up to 36 months following a qualifying event that results in the loss of coverage.
Qualified beneficiary
Any employee, spouse, or dependent child who on the day before a qualifying COBRA event, was covered under the employers group health plan.
Qualifying event
In life insurance, a condition or event that triggers the payment of accelerated benefits, such as an illness that is expected to reduce the insured’s life expectancy to 24 months or less. Under COBRA, one of the following events that results in loss coverage by a qualified beneficiary: employees death or termination; reduction of hours making employees ineligible for coverage; legal separation of employee and eligible dependent or spouse; eligibility for medicare; or child’s ceasing to be a dependent.
Extension of benefits
a provision in a medical expense plan under which benefits are extended for any covered employee or dependent who is totally disabled at the time coverage would otherwise terminate. The disability must have resulted from an injury or illness that occurred while the person was covered under the group contract. The length of the extension generally ranges from 3 to 12 months.
Medigap insurance
an individual or employer-provided medical expense plan for persons aged 65 or older under which benefits are provided for certain specific expenses not covered under medicare. These can include a portion of expenses not paid by medicare because of deductibles, coinsurance, or copayments, and certain expenses excluded by medicare. in individual insurance, also referred to as a medigap policy.
Hospital indemnity insurance
A medical expense policy that pays a fixed dollar amount for each day a person is hospitalized, regardless of the other insurance.
Specified disease insurance
a type of medical expense coverage that provides benefits for persons who have certain specific diseases or medical events, such as cancer or heart attacks. The policy may pay a specified dollar amount, regardless of actual medical expenses and without regard to other coverages.
Critical illness insurance
a form of supplemental medical expense insurance that provides a substantial one time lump sum cash benefit for listed critical illnesses.
Medicare select policy
a medigap that pays benefits for nonemergency services only if care is received from network providers.
Temporary medical insurance
short-term medical insurance that generally provides coverage for periods between 30 days and 1 year while a person is between medical expense plans.
International travel medical insurance
interim medical insurance for international travelers. It is usually folded into a broader policy to cover many non-health-related travel contingencies.
COBRA continuation for surviving spouses
Coverage may also continue for the survivors of deceased active employees and/or deceased retired employees.
COBRA for laid off workers
Medical expense coverage can be continued for laid-off workers, and large employers frequently provide such coverage for a limited period.
Conversion
Except when termination results from the failure to pay any required premiums, medical expense contracts usually contain (and are often required to contain) a conversion provision, whereby most covered persons whose group coverage terminates are allowed to purchase individual medical expense coverage without evidence of insurability and without any limitations because of a preexisting-conditions provision.
Covered persons commonly have 31 days from the date of the group coverage’s termination to exercise this conversion privilege, and coverage is then effective retroactively to the date of termination.
Conversion Privilege
- Requires no evidence of insurability
- Provides full coverage of preexisting conditions
- Allows 31 days for conversion
- Coverage retroactive to start of 31-day period
- Includes right to convert dependents’ coverage
- May not be available to anyone covered by Medicare
- May not be available if conversion would result in overinsurance
HIPAA
Health Insurance Portability and Accountability Act
PPACA
Patient Protection and Affordable Care Act (PPACA)
ACA
Affordable Care Act
The Patient Protection and Affordable Care Act along with the Health Care and Education Reconciliation Act both attempt to do the following:
- expand access to health care coverage for all citizens
- make health care coverage affordable for all citizens
- improve the quality of care that consumers receive
- promote preventive care and wellness
- increase transparency in the health care system
- shift the burden of rising health care costs away from the American consumer
health insurance exchange
A health insurance exchange is a federal or state-regulated marketplace/platform that
allows small businesses and individuals to shop for health insurance plans; it allows them to compare various standardized plans and choose the one that suits their specific needs.
how many people have medicare supplements
more than 60 percent of individuals aged 65 and older have some type of coverage to supplement Medicare.
High risk pool
In recent years, more than half of the states have established some type of high-risk pool, whereby anyone turned down for medical expense coverage in the normal marketplace can obtain coverage through the pool. Although these pools vary among the states, basic
major medical coverage is usually available. Premiums tend to be higher than regular medical expense insurance, but state subsidies keep premiums below the level needed to fully cover expenses and claims costs.
The term group health plan as
used in the act is broad enough to include:
The term group health plan as
used in the act is broad enough to include medical expense plans, dental plans, vision care
plans, and prescription drug plans, regardless of whether benefits are self-funded by the
employer or provided through other entities, such as insurance companies or managed
care organizations.
