Chapters 12-14 Flashcards
A type of health insurance policy that replaces that insured’s income if he or she becomes disabled and unable to work.
Disability Income Insurance
A health insurance provision that allows renewability if certain stated conditions are met by the insured
Conditionally Renewable
A health insurance provision that gives the insurance company the right to terminate coverage at the policy anniversary, usually an annual premium date.
Optionally Renewable
A renewability provision with a health insurance contract that allows the insurance company, at its option, to terminate or renew the policy
Cancellable
A provision that gives the policyholder the right to review the policy for a stated number of days, usually 10, and receive a full refund if the policy is returned to the insurance company
Free Look
A health insurance rider that takes away coverage that the policy would normally provide because of a preexisting condition.
Exclusion Rider
A specified number of days after the policy’s effective date that coverage is not available for sickness, though accidents are covered.
Probationary Period
Mandatory insurance purchased by almost all employers to cover an
employee’s injury, disability, death, or medical expenses due to occupational causes.
Workers Compensation
An option or rider that allows the policyowner to purchase additional coverage without evidence of insurability.
Guaranteed Insurability
A renewability provision with a health insurance contract that allows the insurance company, at its option, to terminate or renew the policy.
Cancellable
A health contract that allows the policyowner to continue the policy for a substantial period of time by paying the premium. Continued coverage is guaranteed; however, the premium rate can change for
classes of insureds.
Guaranteed Renewable
A health insurance provision that allows renewability if certain stated conditions are met by the insured, such as full-time employment to age
65
Conditionally Renewable
A health insurance provision that gives the insurance company the right to terminate coverage at the policy anniversary, usually an annual
premium due date.
Optionally Renewable
A health insurance contract that guarantees the continuation, for a
substantial period of time, and the premium
Noncancellable
Service organization that geographically provides protection against the
cost of hospitalization. _________ pays benefits directly to the participating hospitals.
Blue Cross
Service organization that geographically provides protection against the
cost of surgeries and other medical care. ___________ pays benefits directly to the participating medical providers.
Blue Shield
Provider of health coverage by contracting with a group of doctors, clinics and hospitals to provide health services to subscribers, also known as members, who pay premium in advance of services needed
Service Organizations
An organization that provides health services to individuals, typically employees, known as members. The _____ contracts with a select group of doctors and other medical practitioners to provide services to
members at agreed-upon costs, prepaid on behalf of the member
Health Maintenance Organization (HMO)
An organization of healthcare providers that agree to provide health care services at a predetermined negotiated fee.
Preferred Provider Organization (PPO)
A type of health maintenance organization (HMO) that allows the member to use in-network or out-of-network services; thus giving members freedom of choice.
Point of Service Plan (POS)
A method of health care to possibly prevent illnesses before they occur.
This is accomplished through routine physical examinations and immunizations (a set of shots given to children at different ages to help
keep them from getting dangerous childhood diseases).
Preventive Care
An arrangement were a primary care physician coordinates all health
care for the HMO member.
Gatekeeper
A method of payment for health services in which the medical provider is paid a fixed amount for each patient without regard to the actual number or nature of services provided. This is a common payment method for an HMO’s primary care physicians.
Capitation
A payment system where the medical provider is paid at the time service is needed.
Fee-For-Service
System of delivering health care and health care services by selected providers, programs of ongoing quality control and utilization review, and financial incentives for members to use these selected providers and procedures
Managed Care
A type of health benefit plan in which the insureds select their health care providers, manage their health expenses, and assume more control in protecting their health.
Consumer-Driven Health Plans
A plan that allows employees to pick from a selection of qualified fringe benefits. The participating employee then pays into the ___ through
payroll deductions. Disbursements from the ___ are made to pay for
unreimbursed medical and dental expenses, deductibles and copayments.
Flexible Spending Account (FSA)
An arrangement where the employer reimburses an employee for health expenses not covered by the group health insurance plan, such as
deductibles or coinsurance amounts. The employer determines how much it will pay for medical expenses and shifts the allocated dollars to
the employee. The employee decides how much will be spent from the account.
Health Reimbursement Account (HRA)
A tax advantaged savings plan that covers current and future medical expenses. In order to establish this account, the participant must have a
high-deductible health insurance policy and not be covered by any other
health insurance plan.
Health Savings Plan (HSA)
A policy provision that defines the scope and limits of coverage. It’s the insurance company’s promise to pay according to the policy.
Insuring Clause
The part of the insurance contract that sets forth the amount, renewal, and frequency of premium payments by the policyowner.
Consideration Clause
A health insurance policy that only covers room and board, if the insured stays overnight in a hospital and the miscellaneous expenses (such as, testing, x-rays, lab work, etc.) that occur because of that stay. It provides first dollar benefits by the insurer, but low coverage limits.
Basic Hospital Expense
A health insurance policy that only covers outpatient physician services and procedures. It provides first dollar benefits by the insurer, but low coverage limits.
Basic Medical Expense
A health insurance policy that only covers surgeries, surgeons, and anesthesiologists. It provides first dollar benefits by the insurer, but low coverage limits.
Basic Surgical Expense
A health insurance policy that does not have a deductible. The company pays first when a claim is submitted.
First Dollar Coverage
A health insurance policy that offers broad coverage and high benefits for hospitalization, surgeries, and physician services subject to
deductibles and coinsurance.
Major Medical Expense Insurance
The amount of loss paid by the policyowner before the health insurance policy pays the claim
Deductible
Under major medical expense insurance, the company insures a percentage of the potential loss and the policyowner pays the remaining percentage. For example, 80/20 means that the company pays 80% of the loss (after the deductible has been met) and the policyowner pays
20% of the loss. It is also called percentage participation
Coinsurance
A type of traditional medical expense insurance designed to reimburse the policyowner for out-of-pocket medical expenses. It characterized by
typically low deductibles ($100-$500), coinsurance and stop loss limits.
Comprehensive Major Medical Expense Insurance
With supplemental major medical expense, it is an amount that is paid by the policyowner after the insurer first pays the basic plan portion
when covered expenses are submitted. See Supplementaryl Major Medical Policy and basic expense policies
Corridor Deductible
In major medical expense policies, a stated dollar limit to the policyowner’s maximum out-of-pocket expenses. Once this limit is reached for the policy year, the insurer pays 100% of remaining expenses.
Stop Loss Provision
Annual cost paid by a policyowner or member for deductibles, coinsurance, or copayments
Maximum Out-of-Pocket
With health insurance, charges other than room and board for a hospital stay. For example: x-ray, testing, laboratory fees, etc. Sometimes called
ancillary expenses.
Miscellaneous Expenses
