Chapter 14 Flashcards
What is the experience rating?
Using the actual claim experience of the individual employer to determine premiums
What are three primary components of a basic medical plan?
Daily room and board, surgical benefits, and miscellaneous benefits
What tax deductible savings account may only be used with a high deductible medical plan?
A medical savings account
Qualified withdrawals from a Health Savings Account are _________ withdrawals.
Tax free
Group insurance is a two party contract between ___________ and the __________.
Employer; insurer
T/F: the surgical section of a basic plan lists the most common operations in a surgical schedule.
T
Adhering to COBRA law is required if any employer with ______ or more employees.
20
List some examples of limited policies.
Hospital only, accidental death, travel accident, cancer only, credit, prescription, and vision
If a person is doubly covered by both Medicare and a group plan, which plan is normally considered primary?
The group plan
Group plan conversion must take place within ____ days after leaving the group.
31
COBRA law allows a former employer to charge a past employee _____% of premiums paid for medical benefit coverage.
102%
What are the characteristics of major medical plans?
High coverage amounts, deductibles, copayments, and blanket coverage
What is another name for outpatient services?
Ambulatory services
T/F: Murphy’s Law states that the larger the database of statistics, the more predictable losses will be.
F; this is the law of large numbers
T/F: Care of the root canal and pulp within the teeth is called endodontics.
T
What federal law provides 12 weeks of unpaid leave and a right to return to the same or similar job position?
The Family and Medical Leave Act
Who pays the costs that exceed the states policy benefit on a basic plan?
Costs that exceed the stated policy benefit in a basic plan are paid for by the insured policyowner
Describe a service plan.
Service plans are prepaid benefit plans that have a contractural relationship with doctors and hospitals
What is the certificate of coverage?
The verification of group participation given to enrolled employees
List the eligible groups for group insurance.
Employer related, trade associations, labor unions, and customer groups
The Age Discriminations in Employment Act does not allow for a reduction in _________ benefits.
Medical
What is the master contract?
A detailed description of the group plan that is given to the employer
If divorced, which parents medical policy would be required to provide coverage for children?
The policy of the parent with custody
What is another name for an indemnity medical plan?
A fee for service plan
What is adverse selection?
A bad risk or selection
The __________ the deductible amount, the less expensive the medical policy.
Higher
Comprehensive major medical combines what two types of policies?
Basic coverage and major medical
T/F: Medical benefits for pregnancy related conditions are paid differently than other medical conditions.
F; benefits for pregnancy related conditions are paid in the same manner as other medical conditions
T/F: care of the tissue surrounding the teeth is called periodontics.
T
The Age Discrimination in Employment Act applies to employers with _____ or more employees.
20
What is a common percentage of expenses an insured may pay for her coinsurance?
20%
COBRA Law allows the dependents of deceased or divorced employees to continue their group benefits for up to ____ months.
36
COBRA law allows a terminated employee to continue her group benefits for up to _____ months.
18
HIPAA rules apply to employer groups of ____ or more employees
2
A Basic Medical plan may also be referred to as a _______________.
First Dollar Coverage plan
What federal law requires employers to provide a high degree of fiduciary responsibility to group plan participants?
ERISA
What type of group plan requires employees to pay all or part of the premium?
A contributory group plan
HIPAA law states that a preexisting condition may only be excluded from coverage for _____ months after group enrollment.
12
Unless he is full time college student, a child’s group medical benefits end at what age?
The age of 26 is common in most states
After a deductible has been satisfied, the insured may also be required to share the expenses by making a __________.
Copayment
HIPAA law describes a preexisting condition as one that was treated within ____ months prior to group enrollment.
6
T/F: An ongoing review of medical care is called case management.
T
When does medical coverage on a newborn child commence?
At the moment of birth
When would medical coverage end for a handicapped child who is dependent on his parents for all of his needs?
Provided the child doesn’t marry or obtain coverage through an employer, coverage remains indefinitely
What is another name for case management?
Utilization review
What are some examples of costs containment techniques?
Preventive care, alternatives to hospital confinement, and outpatient services
What dental plans have deductibles, copayment, and pay benefits based upon a UCR value?
Nonscheduled plans
Groups underwriting is _________ liberal than individual underwriting.
More
Describe a stop loss feature.
A feature that limits the amount of expenses an insured may pay toward her medical bill
When does a Notice to the Applicant regarding privacy issues need to be given to an applicant?
No later than when the policy is delivered
Explain the concept of Coordination of Benefits.
This occurs when multiple policies pay in a particular order to eliminate overpayment of a claim
What dental plan has no deductible or copayment and provides first dollar coverage on a predetermined basis?
Scheduled (basic) plan
What is the dollar amount that must be paid by the insured prior to benefits being paid by their medical plan?
The deductible
What are some of the goals of HIPAA regulation?
Standardizing the preexisting condition definition and increasing portability of existing coverage
Describe community rating.
Using the claim experience of all
Local subscribers to determine premiums
Normally, are individual medical premiums a deductible item?
No
The Family and Medical Leave Act applies if an employer employs _____ or more employees within ____ miles of the worksite.
50;
75
Medical expenses that exceed _____% of adjusted gross income may be tax deductible.
7.5%
T/F: Employee paid group medical premiums are deductible to the employer.
T
What is name for the diagnostic and preventative care of the teeth and gums?
Dental coverage
Health savings account contributions are __________ to bother the employer and employee.
Tax deductible
A health savings account must be used with a ________ deductible medical plan.
High
Define the Doctrine of Comity.
The state in which the contract is delivered in the state of regulatory jurisdiction
What type of plan is 100% employer paid for all eligible employees?
A noncontributory group plan
Per HIPAA, if there has been no lapse of coverage ____+ days, previous coverage may be applied against the new plan.
63
