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
What is the absolute requirement to be covered by Medicare?
An individual must be fully insured according to Social Security which includes accumulating at least 40 credits
What is the initial enrollment period for Medicare?
The 3 months prior to the 65th birthday: starts on the 65th birthday
The 65th birthday, birth month and the 3 months after the birth month: starts the first day of the following month following enrollment
What is the Medicare special enrollment period for working past age 65?
Clients have 8 months to enroll following the earlier of (1) the first full month of their employment ending or (2) their health coverage through their employer ending
What happens if someone does not sign up for Medicare Part A and B at the required initial enrollment period?
There is an annual enrollment period between Jan 1 and Mar 31 every year. Coverage takes place July 1 and there is a 10% penalty per year beyond 65 that is permanent
What is Medicare Part A?
Four main benefits areas:
-Inpatient hospital care
-Post hospital extended care in a skilled nursing facility
-Post hospital home health services
-Hospice Care
What is Medicare Part B?
Pays for physicians and for other outpatient treatment, certain preventative services, screening tests, and home dialysis
What is Medicare Part C?
Provides four program alternatives:
-HMO
-PPO
-Private fee-for-service
-Special needs plans
What is Medicare Part D?
Prescription drug coverage
In Medicare, what are lifetime reserve days?
The 60 days of care between 91-150. You only get 60 days in a lifetime. After that, the individual is responsible for all costs.
How many Medigap plans are there, when can you sign up, and what are the restrictions to having Medigap insurance?
There are 10 plans
You can sign up for up to 6 months following Medicare Part B coverage
You cannot have MediGap and Part C coverage simultaneously. Also, you can only have one MediGap plan.
What are the key aspects to a disability insurance policy?
The definition of disabled
The elimination or waiting period
The maximum benefits payable
The maximum benefits period
Renewal provision
The premium structure
What is a modified Own Occupation disability definition?
That someone is considered disabled only if they cannot perform not only in their specific occupation, but also a related field to their occupation.
Ex: scientists cannot work in the lab, but can teach science = not disabled.
What is the difference between narrow and broad definitions of disablement?
Narrow: must be unable to work in ANY occupation to receive benefits
Broad: unable to work in ones own specific occupation to receive benefits (highest premiums)
What is the split definition of disablement and why?
Disability will pay first 2-5 years as broad, own occ disablement. Then will move to narrow, any occupation disablement. This is to encourage disabled to find a new skill in the first 2-5 years if they can no longer work in that field.
What is the elimination period of a disability policy?
Deemed a “time deductible”, it is the chosen length of time one will wait to receive disability payments.
What is the difference between the elimination period and the probation period?
The elimination period is the amount of time between disability and the start of payments.
The probation period is the amount of time between policy purchase and the policy is determined in force.
What is the difference between a non cancelable policy and a guaranteed renewable disability policy?
Non-cancelable: the insured can renew the policy for the full term as outlined in the policy and the company cannot change the premium under any circumstances
Guaranteed: the insured can renew the policy for the full term as outlined in the policy, but the company can change the premiums so long as they change the entire policy class.
What are conditionally renewable disability policies?
Two flavors:
-Gives the company the right to disallow renewal of the policy under certain conditions
-Allows the insured to renew the policy, usually up to age 70
What is presumptive disability?
When the loss of an appendage (foot, feet, hand(s)), would lead a company to believe the total disability is a foregone conclusion,
What are partial and residual disability benefits?
Partial: to encourage someone to return to work, a reduced payout will supplement a likely lower income for reduced work until the insured can get back to full-time or benefit period ends.
Residual: It is determined that the insured is never going to be 100% again and disability will continue to payout a reduced, but supplemental payout until the benefit period ends.
What is the relation of earnings clause in a disability policy?
Allows the insurance company to underwrite at the time of disability so that they can provide a benefit equal to the pay the insured was making at the time of disability.
What are the various disability riders?
Cost of living: increases benefits (once payouts begin) to keep up with inflation
Additional insurance Rider (AIR): increases the policy benefits while the insured is NOT disabled
Social Insurance Supplement (SIS): splits the cost with social security or workers comp which reduces payouts and premiums
What is the most important and influential factor in disability insurance?
Occuptation
What are the general taxation rules on disability insurance?
TAX ONCE
If the premiums were paid for by the insured with after-tax dollars, the benefits are usually not taxed
If the premiums were paid for by the employer or by pre-tax dollars, then the benefits are taxable.
Generally speaking, about how much disability insurance can you get (percentage of payout)?
Around 2/3rds of your monthly income
What are the two ways to trigger LTC benefits?
An inability to perform two activities of daily living: Bathing, continence, dressing, eating, toileting, transferring
Impaired cognitive ability: dementia, strokes, Alzheimer’s, other brain damage
In LTC insurance, what is the restoration of benefits?
If the client returns to good health after the benefits are used for a few months, usually the elimination period will begin again, and then the full insurance benefits will restart.
What is a limited pay policy rider?
Instead of annual increases in premium, the limited pay guarantees a rate for 10 years (albeit a higher rate).
What is the bed reservation guarantee rider?
Guarantees that a nursing home bed will remain reserved for the insured when the insured may be off the property for a few days in hospital or temporary home
In LTC, what is “Medical Requirement”?
It is the requirement that a doctor state that LTC benefits are necessary for an individual’s overall health and well-being.
What are the two general rules to prevent annuities from being counted as available assets in the medicaid (LTC) calculation?
-Must be an insurance annuity and must be immediate
-Annuity payout must be structured to disburse a complete payout during the annuitants lifetime
What is the Additional Insurance Rider (AIR)?
It is a combination of COLA rider and guaranteed insurability option. It automatically increases the benefit by 1.5%-2.5% each year. At the end of 4-5 years, the company will determine if the insured is eligible for additional increases based on income.
What are the tax benefits of a qualified LTC policy?
Benefits are not generally taxable, subject to a per-day limit
How many months of COBRA continuous coverage is available for a full-time spouse who change status to part-time?
18 months
State the “any occ” key phrase
Narrowest definition of disability
State the “own occ” key phrase
Broadest definition of disability
How many ADLs and for how long until LTC insurance is triggered?
2 ADLs for 90 days
Which of the following are mandatory Medicaid benefits?
- Inpatient hospital services
- Laboratory and x-ray
- Eyeglasses
- Family planning services
1, 2, & 4
True / False. Medigap policies must accept all applicants who apply within the first nine months of qualifying for Medicare.
False. 6 months, not 9.
Which of the following statements pertaining to qualifying for Social Security disability benefits is CORRECT?
- To be awarded Social Security disability benefits, an individual must suffer from a mental or physical impairment that prevents her from engaging in any substantial gainful employment.
- The disability must be expected to last at least 12 months or result in the death of the individual.
- The disability must have been a result of a work-related injury.
Statements 1 and 2
Which of the following statements regarding business overhead expense (BOE) insurance is CORRECT?
- The policy covers ongoing expenses of the business, such as rent and clerical salaries, if the owner is disabled.
- Policy premiums are tax-deductible by the corporation.
- The policy provides the disabled business owner with an income stream during his disability.
- The policy covers all profits lost during the owner’s disability.
Statements 1 and 2
Which of the following are mandatory Medicaid benefits?
- Inpatient hospital services
- Laboratory and x-ray
- Eyeglasses
- Family planning services
1, 2, & 4
Which of the following statements concerning the cost of long-term care and Medicare are CORRECT?
- Medicare pays for a limited amount of skilled nursing care.
- Medicare will pay 100% of the first 20 days of skilled nursing care.
- After 20 days, Medicare will pay everything over a specified amount per day for 80 days of skilled nursing care.
- Medicare benefits for long-term care are subject to substantial limitations.
All of them
Which of the following statements regarding Medigap required provisions is CORRECT?
- Medigap policies must be guaranteed renewable.
- Medigap policies must have a 90-day free-look period.
- Medigap policy benefits must be automatically adjusted for changes in Medicare.
- Pre-existing condition limitations may not last longer than 6 months from the date of issue.
1, 3, & 4
