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Insurance > Health Insurance > Flashcards

Health Insurance Flashcards

1
Q

Comprehensive Major Medical Plans

A

Based on calendar year deductible, coinsurance percentage, and stop loss amount

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2
Q

Deductible

A

Amount that is paid before coinsurance begins
Most plans have separate limit for each person

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3
Q

Coninsurance

A

Percentage of covered expenses paid by the plan

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4
Q

Stop loss limit

A

Breakpoint
Once it’s reached the insurance company pays 100% of the expenses

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5
Q

Continuance and Portability

A

Affordable Care Act requires medical expense insurers to continue coverage regardless of claims as long as the premium is paid

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6
Q

Medicare Part A

A
  • hospital insurance
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7
Q

Medicare Part A - Eligible Persons

A
  • all persons age 65 and over who are entitled to SSA or railroad benefits
  • disabled people receiving benefits for at least 2 years, regardless of age
  • disabled get part A and B
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8
Q

Medicare Part A - Benefits

A
  • hospital stays
  • post hospital extended care in nursing home, up to 100 days
  • unlimited post hospital health services
  • hospice
  • pay for first 3 pints of blood or donate it. Rest covered
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9
Q

Medicare Part A - Limitations

A
  • services outside US
  • if covered by employer group insurance, entitled to veterans benefits, covered by workers comp then Medicare is secondary
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10
Q

Medicare Part B

A

-Voluntary
- same eligibility as Part A
- premiums
- deductibles
- 80/20 coinsurance
- no stop loss

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11
Q

Medicare Part B - Benefits

A
  • doctors services
  • diagnostic tests
  • outpatient services
  • unlimited home health services
  • free preventive care
  • behavioral screening
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12
Q

Medicare Part B - Exclusions

A
  • dental
  • eyeglasses
  • hearing aids
  • immunizations
  • prescription drugs
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13
Q

Medicare Part D

A

Plans run by an insurance company approved by Medicare
- drug manufacturers give 50% discount
- need part a and b

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14
Q

Medicare Supplemental (Medigap)

A
  • plans A through J
  • include benefits to pay deductibles and coinsurance plus more
  • one medigap policy per person at a time
  • can’t offer prescription drugs
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15
Q

Health Maintenance Organizations (HMOs)

A

provides services to a group of subscribers in return for a payments and delivery for fixed premium

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16
Q

Capitation (HMO)

A

A monthly fee is paid to the provider. In return the individual receives all the medical care required during the year

17
Q

Gatekeeper (HMO)

A

care is managed by a primary physician who is responsible for determining what care is provided and when the individual should see a specialist

18
Q

Disadvantage to HMO

A
  • have to go through gatekeeper
  • not covered when out of network, besides emergency
  • have to get care from those affiliated with HMO
19
Q

Preferred Provider Organizations (PPOs)

A

represent group of health care providers contracting to provide medical care at reduced fee

20
Q

Income Tax Implications - Health Care

A

-premiums for employees and dependents are tax deductible by the employer
- employer premiums don’t create income tax liability for employee
- benefits are taxable if they exceed medical expenses
- self employed may deduct above the line
- some large corps report cost on W-2, its still not taxable

21
Q

COBRA

A
  • employers providing group or self funded coverage have to offer terminated employees right to buy continued health coverage (identical)
  • companies under 20 employees (for half the year) are not required
22
Q

COBRA and Disability

A
  • if disabled, within 60 days of triggering event can extend COBRA continuation by 11 months (total 29 months)
23
Q

Electing COBRA

A
  • election period starts on date of qualifying event and up to 60 days after the actual notice of the event
  • once elected, up to 45 days to pay premium
  • cost cannot exceed 102% of cost of plan for similar employee
24
Q

Medicare Part B - Election when covered by workplace plans

A
  • if you or spouse is still working and has coverage through employer, my be wise to delay part B
  • when employment ends 3 options
    1. elect COBRA (higher cost)
    2. sign up for part B within 8 months without penalty of increased premium
    3. once you sign up for Part B, medigap enrollment period begins
25
Q

Coverage for dependents under 19

A

no child under 19 can be denied coverage because of pre-existing medical conditions

26
Q

Health Savings Account (HSA)

A
  • individual or family
  • deductible up to limits, 3,850 (s) and 7,750 (f)
  • need HDHP, min ded. 1,500 (s) , 3,000 (f)
  • HDHP out of pocket, 7,500 (s), $15,000 (f)
  • no other plan and below medicare age
  • over 55 get 1,000 catchup
  • employer contribution not required
27
Q

HSA Qualified Expenses

A
  • doctors visits
  • surgical procedures and hospitalization
  • OTC prescription drugs
  • acupuncture and chiropractic care
  • eye exams, glasses, laser eye
  • hearing test and aids
  • dental exams and work/dentures
  • alcohol drug treatment
  • insulin and diabetic testing
  • LTC expenses
  • OTC drugs
  • feminine hygiene
  • insect repellant and itch cream
  • sunscreen and aloe
  • acne treatment
  • eye drops
28
Q

Archer Medical Savings Account (MSA)

A

No new MSA after 2005

29
Q

Health reimbursement arrangements (HRAs)

A
  • solely employer funded and reimburses employees for substantial medical expenses up to a maximum
  • could reimburse out of pocket costs of HDHP
30
Q

Characteristics of HRA

A
  • cant be apart of cafeteria plan (solely employer funded)
  • excluded from employee gross income
  • cannot offer cash out option
  • can reimburse after employment
  • cant be used for same expense covered by FSA. HRA first
  • employer retains excess unused money in HRA
31
Q

Group Health Conversion Plan

A

terminating employee may exercise conversion privilege to purchase conversion plan for health insurance
- notification should be made immediately after termination or 180 days before end of COBRA
- application before temination ends and pay premium within 31 days

Insurance (10 decks)

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