Health Insurance Flashcards
Hospital Insurance
-expense reimbursement or service contract
Hospital insurance expense reimbursement
- pays for all or parts of the hospital stay
Hospital insurance service contract pays for what (time period)
-pays for a specific number of days
Surgical Expense
-reimbursement contract
-schedule of payment based on surgery type
-customary payment unless procedure is not customary then pays more
Health Maintenance Organization
-comprehensive & lower cost to insured
-contracted physicians and facilities are employee of HMO
-pre-set costs
-see primary doc first before specialists
Physicians expense health ins.
nonsurgical physician expenses
Preferred Provider Organization
- like HMO but can receive care outside of network
-out of network causes higher deductibles
-Docs not employees - negotiate prices for increased patient count
Deductible
-stated dollar amount per family member per each visit or procedure
-overall max $ per calendar year
Coinsurance
-copayment in addition to deductible
-percentage of costs for service that the insured pays over the deductible
Stop loss
amount that includes the deductible and coinsurance
Coordination of benefits provision
-2 policies covering the same insured
-after first policy pays, 2nd policy pays the difference
-married couple person w/earlier birthday in the year
COBRA
-keep your insurance at the group rate after a qualifying event
-employee, spouse, child, who was on the plan day before qualifying event
Can you get COBRA if you quit or are fired?
Yes - as long as you weren’t fired for gross misconduct
Can a child get COBRA once they’re not a dependent?
yes child ceasing to be a dependent is a qualifying event
COBRA Qualifiers
- if your hours are reduced
-qualify for medicare
-death of covered employee
-termination, retiring, quitting (not gross misconduct)
-divorce or legal separation
-child ceases as dependent
How long can you get COBRA after death, divorce or medicare
36 months
How long can you get COBRA if you’re fired or have reduction in hours
18 months
How long can you get COBRA if you meet disability requirements?
29 months
How long do you have to notify your employer after a qualifying event?
60 days
When does COBRA election period start?
The day of the qualifying event
Max percent charge for COBRA
102% of regular coverage for employee - 2% is for employer admin costs
Can beneficiaries pay COBRA premiums in installments?
Yes and you get a 30 day grace period on each installment
Medigap
medicare supplement insurance - fills in gaps after medicare is exhausted
Part A hospitalization benefits
-Lifetime reserve of 60 days
-1 time deductible for hospital stays 60 days or less
-61-150 days = co payment or cost sharing
Medicare Blood Payment
payment for first 3 pints of blood each year
Medicare Part A Benefits
-hospital services up to 90 days in each benefit period
-period ends when out of hospital for 60 consec days
- lifetime reserve of 60 addtl days to those who exhausted 90 days
Under Part A - what resource do you have if you don’t require continuous hospitalization?
-skilled nursing care
-physician must certify condition occurred within past 30 days
-prior hospitalization must have last at least 3 days
When does a new benefit period begin under part A?
-After you’ve been out of the hospital for 60 consecutive days
-upon subsequent hospitalization you have to pay the deductible again
When would you pay a Part A premium
only required for a person or spouse who doesn’t have 40 quarters of qualified employment
When would you pay a Medicare part A premium?
When you have less than 40 quarters of qualified employment
How much would you pay for part A if you had between 30-39 quarters of medicare qualified employment?
$278 a month in 2023
What is the max hospital services days part A will pay in 1 benefit period?
90 days
What can you get under part A if you no longer require continuous hospital care?
Skilled nursing care
To qualify for skilled nursing care after a hospital stay under Part A
-prior stay must have been at least 3 days
-physician must certify that nursing or rehab is required for a condition treated in previous 30 days
How long is skilled nursing fully paid for by Part A
Benefits paid in full for 20 days of skilled nursing
Medicare Part D covers what
Drugs - D for Drugs
How would you pay for days 21-100 of Skilled Nursing under Part A
Copay
When does Medicare stop paying for skilled nursing under part A?
After 100 days
Should skilled nursing under Part A substitute for LTC coverage?
No
How many home health visits are covered under Part A?
100 during an illness that requires home health care - hospital stay need not preceed the care
How much would your copay be for home health equipment under Part A?
20% copayment for oxygen tanks, hospital bed, dialysis, iron lung
How can you qualify for hospice under part A?
certified as terminally Ill - life expectancy of 6 months or less - can get 210 days of care
What is the max hospice days under Part A?
210 - unless you’re recertified as terminally ill
What does part B cover
physicians services, home health services not requiring hospital stay, diagnostic test, medical equipment, all outpatient services of a hospital
Do you pay a deductible for Part B?
Yes, AFTER THAT 80% of the services are covered and you pay for the remaining 20%
Which Part would x-ray and pathology services fall under?
Part B
How much of the cost will Part B pay for X ray and pathology services
100%
Does Part D Cover brand name?
yes - generic and brand name
Do you have a premium on Part D?
Yes monthly
What is not covered under part A?
Custodial care, cosmetic surgery, private rooms, televisions
Who is eligible for Part D?
everyone covered under medicare regardless of income, health status etc.
What type of payments would you make under part D?
cost of prescriptions, deductible, and/or coinsurance
Can you pay more for better coverage under part D?
Yes - some plans offer more coverage and and additional drugs for a higher premium
Benefits NOT covered under part B
cosmetic surgery, glasses, dental care, routine foot care, orthopedic shoes, hearing exams, eye exams
In a PPO plan, who selects the doctor?
The patient
Is there a copay with PPO?
Yes
How many months must you be on social security disability before you can get medicare?
24 months
If you’re eligible for social security disability and have ALS can you get medicare?
Yes
If you’re on dialysis and have end stage renal failure what coverage can you get?
Medicare
Does part A cover diagnostic tests?
No
Will the premium schedule ever change in a non cancellable policy?
Not unless the policy owner purchases additonal coverage in the future
Who funds a health reimbursement program?
The employer
Who can fund an HSA?
Employee and employer
Does first dollar coverage require out of pocket expenses?
No
