Health, Disability, and LTC Flashcards
What are the 10 triggering events that cause a change in health care outside of the annual enrollment period?
Marriage: newlyweds can stay under respective parents until 26
Divorce: COBRA for 36 months
Death: COBRA for 36 months
Disability: COBRA for 29 months
Losing/changing jobs
Moving
Birth: first 30 days free
Age 26: no longer under parents
Age 65: eligible for medicare
In changing jobs, what are the benefits of the Health Insurance Portability and Accountability Act (HIPAA)?
HIPAA provides that group insurance of the new job, could not enforce the existing medical conditions clause if an employee was covered by the prior employer’s health plan for more than 12 months AND fewer than 63 days elapsed between the two coverages
What are the qualifying events and continuation periods of coverage for COBRA?
Termination of the employee: 18 months
Death of covered employee: 36 months for dependents
Divorce or legal sep: 36 months for dependents
Loss of dependent status: 36 months
Covered employee eligible for Medicare: 36 months
Employee meets SS def of disabled: 29 months
How many days after notification must a recipient elect for coverage under COBRA?
60 days
What is the Small Business Health Options Program (SHOP)?
Enables small businesses with fewer than 50 employees, to offer and control the type of coverage it provides its employees. The owner chooses the open enrollment period and waiting period. A 50% of premium tax credit is offered to business with fewer than 25
What are the important ages of health insurance?
30 days: newborns to be covered
26 years old: children have to get their own policy
55 years old: catch up provisions for HSAs
65 years old: eligible for Medicare
What are the assets that generally count against Medicaid eligibility?
(think somewhat liquid assets)
Checking and savings accounts
Stocks and bonds
CDs
Real property other than the primary residence
Additional vehicles (if more than one)
What is Medicaid / Children’s Health Insurance Program (CHIP)?
Think - medical aid
Federally mandated and partially funded, but state managed health insurance for low income families / children.
Must be a US citizen and meet income thresholds
In a major policy provision, what are covered charges?
Two basic approaches to covered charges; either list the policy benefits and all else is excluded or just state “medically necessary products & services” and list all of the exclusions
In major policy provisions, what are internal limits?
Excluded treatments or controls that limit the extent to which certain benefits can be used
In major policy provisions, what is utilization review?
The process by which a patient must get pre-certified for hospitalization or other high-cost medicine is recommended.
In major policy provisions, what is case management?
Another cost control. In the case of an expensive illness, medical professional coordinate with the case manager to setup a long-term care plan.
In major policy provisions, what is the coordination of benefits?
Occurs when there are two working adults, each covered by their respective health plan which also provides care for the spouses. This creates a complexity for which company will be primary, providing coverage to a point, and which will be secondary, covering what the primary doesn’t
What is the difference between copayment and coinsurance?
Copayment is a set dollar amount for each type of product or procedure. Coinsurance is cost split percentage of the total bill of a given product or procedure
What is the maximum out of pocket (MOOP) limit?
The maximum amount of costs the insured will pay for each product or procedure. This includes deductibles, coinsurance, copays. The MOOP does not apply for exclusions or non pre-certified services.
What are examples of riders or supplemental coverage to health policies?
Dental, vision, and accident insurance
What are post payment (indemnity) health care plans?
These are fee-for-service plans in which the insured/patient receives care and then the insurance is billed. Whatever the insurance won’t cover must then be covered by the insured.
What type of health coverage is a comprehensive major medical policy?
Indemnity plan which incorporates essential medical services under one plan
What is a daily benefit healthcare plan?
An indemnity plan… sort of. It just pays a fixed amount when the insured is sick, disabled, in the hospital. They don’t really cover health expenses.
Name these managed care plan acronyms:
HMO
PPO
POS
EPO
PSN
Health maintenance organization
Preferred provider organization
Point of sale
Exclusive provider organization
Provider service network
How do managed care (prepaid) plans work?
Individuals are called subscribers instead of insureds
They control the cost of healthcare through salaried providers, capitation, negotiated fees, limited benefits, limited access to specialists
Capitation assures that the primary care physician (PCP) is paid a fixed fee for every subscriber who names the physician as their PCP.
What are HMOs?
KEY: HMOs provide the service and the financing whereas most insurance only provides the financing
Doctors and staff are employees of the HMO. Subscribers actually may get quite a few improved health services from an HMO and the doctors get paid better, almost like an indemnity plan. However, anything outside the HMO that isn’t an emergency is all on the subscriber.
Subscribers typically pay a copay for most services. Also, HMOs can use the PCP as a gatekeeper to any additional medical services.
What are Preferred Provider Organizations (PPO)?
A group of providers that have agreed to be part of the plan which pre-negotiates charges for the various services, usually at a discounted rate. This type of plan doesn’t require subscribers to choses a participating PCP, but encourages it through use of “in-network” vs “non-network” percentage cost coverage
What are Point of Service (POS) plans?
This a hybrid between HMOs and PPOs. Usually, the subscriber must choose a PCP, but unlike an HMO, that won’t stop the subscriber from using and being covered for out of network services. This plan provides incentives to use the lowest cost providers.
What is an Exclusive Provider Organization (EPO)?
Similar to an HMO except the medical services are contracted out. The EPO handles the financing
What are Provider Service Networks (PSN)?
These are typically a coop between doctors and hospitals.
In major policy provisions, what are some of the most common sections or components of the actual policy?
Covered charges
Case management
Internal limits
Deductible
Exclusions
Coinsurance
Pre-existing conditions
Maximum out of pocket expenses
Utilizing review
Coordination of benefits
Supplemental coverage
Generally, what are taxation guidelines with health insurance?
Employer contributions are not taxable
Benefits paid from the plans are not taxable
Premiums paid by the employee are usually pre-tax
Itemizing, unreimbursed qualified expenses in excess of 7.5% can be claimed
What are the 3 types of people who qualify for Medicare?
When the person reaches age 65
When a younger person who qualifies for SS disability insurance after 24 months
Anyone who has end-stage renal (kidney) disease
