Chapter 5 Flashcards
2 types of perils with accident and health insurance
- Sickness
2. Accidental injury
Major types of losses In health insurance (4)
Medical expenses
Loss of income from disability
dental expense
long term care expense
Common exclusions in health products (6)
-war
-self-inflicted injuries
-elective cosmetic surgery
-conditions covered by workers comp
-conditions covered by government plans
participation in criminal activities
Basic Medical Insurance - Limited protections (Back in the early days)
Hospital expense, medical expense and surgical expense
Major Medical insurance
Coverage and policy features
Major Medical coverage
Comprehensive coverage for hospital expenses
Catastrophic medical expenses
benefits for long term injury or illness
Major medical policy features
blanket and lifetime per person limits
deductibles and coinsurance apply
large benefit maximums
Health Maintenance organizations (HMOs)
features preventative care, outpatient benefits, alternative care.
HMOs are not considered insured, they are subscribers
Preventative care
Helps reduce the cost of health care. It is set up to prevent a person fom medical problems.
Cost containment
Managed care plans such as HMOs and PPOs are designated to contain costs by controlling the behavior of the plan participants
What is the PCP?
Ptrimary care physician. Also known as a gatekeeper
What is a PPO?
Drug stores will contract with independent hospitals and physicians within a certain area. This came after a HMO in the late 70s. Do not have to have a gatekeeper
Elements of a PPO
-Greater selection of providers
-providers are paid on a fee-for-service basis
no PCP referrals
HMO vs PPO
HMO - encourages preventive care
PPO - In network and out of network providers
Consumer Driven plans? (3)
FSA, HRA and HSA
FSA
Immediate tax break. Using that pre tax money to pay for deductables and co pays.
HRA
contributor is employer only
HSA
Directly related to a high ductable health plan
Group health insurance basics
There is a master policy that goes to the employer. Group underwriting is very leanient.
Noncontributory
This means that the employer pay 100% of premium. If the plan is contributory then they share the premiums
Entire contract
copy of application and the policy. Need this if ever go to court
Free look period
Insured gets 10 days of free look to cancel the policy (buyers remorse)
Notice of claim how many days do you have to let company know
Insured must notify the insurer of a loss within 20 days
