Chapter 15 - Leo Flashcards
Define Individual Medical Expense Insurance
Insurance that protects and individual or family for covered medical expenses because of sickness or injury.
Define Major Medical Insurance
Health insurance designed to pay a large portion of the covered expenses of a catastrophic illness or injury
Define Copayment
Flat amount that the insured must pay for certain benefits, such as office visit or prescription drug.
Define Annual Out-of-Pocket (stop-loss) Limit
Provision in medical expense policies by which 100% of covered medical expenses in excess of the deductible are paid after the insured incurs a certain annual amount of out-of-pocket expenses.
Define Preferred Provider Organization (PPO)
A manged care plan that contracts with health-care providers to provide certain medical services to the plan members at discounted fees. To encourage patients to use PPO providers, deductibles and coinsurance charges are reduced.
Define Health Savings Account
A tax-exempt or custodial account established exclusively for the purpose of paying qualified medical expenses of the account beneficiary who is covered under a high-deductible health insurance plan.
Define Long-term Care Insurance
A form of health insurance that pays a daily benefit for medical or custodial care received in a nursing facility or hospital. Home health benefits may also be provided.
Define Benefit Triggers
Requirements that determine whether the insured is chronically ill and eligible for benefits.
Define Activities of Daily Living (ADLs)
Eating Bathing Dressing Transferring from a bed to a chair Using the toilet Maintaining continence.
Used to determine if a person is chronically ill.
Define Elimination Period
Waiting period in health insurance during which benefits are not paid. Also a period of time that must be met before disability benefits are payable.
Define Disability-income Insurance
Insurance that provides income payments when the insured is unable to work because of sickness or injury.
Define Total Disability
A term that varies by insurers and type of policy. In individual disability income policies, total disability can be defined as (1) inability to perform the material and substantial duties of your regular occupation; or (2) inability to perform the duties of any occupation for which you are reasonably fitted by education, training, and experience; or (3) inability to perform the duties of any gainful occupation; or (4) loss-of-income test. In many waiver-of-premium provisions in life insurance, total disability means that, because of disease or bodily injury, the insured cannot do any of the essential duties of his or her job, or any job for which he of she is suited based on schooling, training, or experience.
Define Partial Disability
Inability of the insured to perform one or more important duties of his or her occupation.
Define Residual Disability
Residual disability means that a proportionate disability-income benefit is paid to an insured whose earned income is reduced because of an accident or illness.
Define Waiver-of-Premium Provision
Benefit that can be added to a life insurance policy providing for waiver of all premiums coming due during a period of total disability of the insured.
Define Guaranteed Renewable Policy
Continuance provision of a health insurance policy under which the company guarantees to renew the policy to a stated age, and whose renewal is at the insured’s option. Premiums can be increased for broad classes of insureds.
Define Noncancellable Policy
Continuance provision in a health insurance policy stipulating that the policy cannot be canceled, that the renewal is guaranteed to a stated age, and that the premium rates cannot be increased.
Define Conditionally Renewable Policy
The policyholder can renew the policy until a specific age;however; the insurer has the right to decline renewal under conditions specified in the contract.
Define Nonrenewable
When a contact cannot be renewed.
Define Guaranteed Issue
A term used to describe applicants for health insurance; coverage for medical expense insurance us guaranteed, and applicants cannot be turned down regardless of their medical conditions.
Define Grace Period
Period of time during which a policy can pay an overdue
Define Reinstatement Provision
Contractual provision in a life insurance policy that allows the insured to reinstate a lapsed policy by payment of premium either with or without an application.
Define Time Limit on Certain Defenses
Provision in an individual health insurance policy that prohibits the company from canceling the policy or denying a claim on the basis of a preexisting condition or misstatement in the application after the policy has been in force for two or three years, except for fraudulent misstatements. Modified by the Affordable Care Act.
What characteristics are found in most individual medical expense policies? 6
- Major medical benefits
- Broad range of benefits
- Calendar-year deductible
- Coinsurance and copayments
- Annual out-of-pocket limits
- Exclusions
What is usually included under a broad range of benefits?
- Inpatient hospital benefits
- Outpatient benefits
- Physician benefits
- Preventive services
- Outpatient prescription drugs
What does a manged care plan provide?
Covered medical services to the members in a cost effective manner, with heavy emphasis on cost control.
What is the requirement for someone to own an HSA?
The beneficiary must be covered under a high deductible health plan to cover catastrophic medical bills.
Who can make contributions to an HSA?
By the beneficiaries, their employers, and family members.
What do proponents argue HSAs can do?
Help keep health care costs down because consumers will be more sensitive to costs, will avoid unnecessary services, and will shop around
What do critics say will result from HSAs?
They will encourage insureds to forego preventative care.
What are the three main forms of LTC plans? 3
- A facility-only plan
- A home health care policy
- A comprehensive policy
What is the difference between reimbursement policies and per diem policies?
Reimbursement policies reimburse actual charges where per diem pays their daily limit even if the actual charges are less than the daily limit.
In a qualified LTC plan, what must be met to receive benefits?
Benefit trigger
What are the benefit triggers that you must meet two of to receive benefits from an LTC plan?
Either:
- The insured is unable to perform a certain number of activities of daily living, or
- The insured needs substantial supervision to be protected against threats to health and safety because of a severe cognitive impairment.
In a nontax-qualified LTC plan, what must be met to receive benefits?
A medical necessity trigger
What is a medical necessity trigger?
If a doctor certifies that long-term care is needed even if the insured does not meet any of the benefit triggers described earlier.
What are LTC partnership programs?
Programs some states have put together designed to reduce Medicaid expenditures by eliminating or reducing incentives of some people to rely on Medicaid to pay for long-term care.
What incentive is used to encourage people to purchase private partnership policies?
Part of all of their assets are protected from the Medicaid spend-down requirements.
How are partial disability benefits different than total disability benefits?
They are paid at a reduced rate for a shorter period.
