Health Ins Flashcards
Health Insurance Portability and Accountability Act (HIPAA)
The Coordination of Benefits clause prohibits the insured from collecting more than 100% of actual expenses incurred.
Pre-existing condition clauses cannot last more than 12 months when going from one group plan to another group plan.
The 12-month period is reduced for every month of coverage that the insured spent under a previous plan
There are two primary types of
group health insurance:
Group Basic Medical Insurance
Group Major Medical Insurance
When the features of these plans are combined into one policy, the policy is referred to as a group comprehensive major medical insurance plan.
Group basic medical insurance covers hospital, physician, and surgical bills, but:
but it typically has low policy limits.
Due to the low policy limits, group basic medical coverage is often used in conjunction with group major medical insurance.
Group major medical insurance coverage supplements basic medical coverage by:
permitting a wider array of services and increasing policy maximums.
Sometimes referred to as group supplemental insurance plans.
The Affordable Care Act of 2010 requires large employers to provide a minimum level of health insurance coverage to employees or face stiff tax penalties. What is considered a Large Employer?
50 or more EE’s
What % Coverage do the ACA plans offer?
60 Bronze Plan
70 Silver Plan
80 Gold Plan
90 Platinum Plan
Health insurance policies obtained in the individual market must provide essential benefits, including:
ambulatory services, emergency services, hospitalization, maternity and newborn care, pediatric services, rehabilitation and mental health services, prescription drugs, and laboratory and preventative wellness services.
Individual Major Medical Insurance Does NOT cover:
Routine eye and dental exams are usually not covered under a major medical insurance policy.
The policy often includes exclusions for self-inflicted injuries and medical procedures that are purely cosmetic in nature.
The Affordable Care Act has removed the lifetime cap for all policies issued after September 2010.
Unlike major medical insurance policies, medical expense insurance policies only cover
specified types of medical expenses.
TYPES OF MEDICAL EXPENSE INSURANCE
Hospital Expense Insurance
Physician Expense Insurance
Surgical Expense Insurance
The 3 Types of Managed Care Plans:
HMO, PPO, POS
HMOs consist of a group of physicians who provide
comprehensive care for their patients and who
are organized in an effort to control the rising cost of health care.
Physicians are either employed by the HMO directly or are in private practice and choose to participate in the HMO network.
* Independent physicians are paid a fixed amount for each HMO member that uses them for primary care.
* Major disadvantages of HMOs are that patient choice is limited by:
the need to establish a network of
approved health care providers.
a primary care physician gatekeeper
for specialized services.
PPO’s Typically:
A PPO typically has a larger provider pool from which to choose.
* Participants are not required to receive services
from preferred providers, but higher deductibles and
coinsurance payments may apply when services are
obtained from providers outside of the network.
COBRA only applies to employers who offer a group health plan and:
have at least 20 employees
The employer must offer coverage for a specific period of time based on these qualifying events:
18 months for reduction in hours or normal termination
36 months for death of a covered employee
36 months for divorce
36 months for Medicare eligibility
Up to 29 months if the employee meets the Social Security definition of being disabled
