Health Insurance Flashcards
Types of Health Insurance Policy
Basic Medical Expense Insurance
Major Medical Insurance
Disability Income Insurance
Medicare Supplement Insurance
Long-term Care Insurance
Basic Medical Expense Insurance
Basic medical expense insurance generally provides the first-dollar coverage with no deductible provision for expenses of hospitalization and doctor’s service and surgical procedures.
Surgical contracts
Surgical contracts provide coverage for the costs of surgical procedures. Some specify a maximum amount of coverage for a representative group of surgical procedures. The stated amount is the most the insurer will pay for one procedure. If a patient needs two procedures during one hospitalization, the more expensive treatment determines the payment.
Surgical schedules
Surgical schedules identify a maximum dollar amount for the most difficult procedure and provide a representative list of other procedures and their reimbursement rates.
For example, a $10,000 surgical schedule pays $10,000 for the most difficult operation, and all other procedures are proportionately less.
Major Medical Insurance
Major medical insurance policies provide coverage for potentially large medical expenses rather than paying for the first dollar of loss.
Limit of Liability
The Affordable Care Act (ACA) requires that all individual and qualified small-group plans have covered essential health benefits (EHBs), and there cannot be dollar limits on the lifetime or annual benefit maximums for these benefits.
Medicare
Medicare is health insurance for people age 65 or older, under 65 with certain disabilities, and any age with End-Stage Renal Disease which is permanent kidney failure requiring dialysis or a kidney transplant.
Medicare Parts
The original Medicare Plan provides Part A (Hospital Insurance) and optional coverage for Part B (Medical Insurance), Part D (Prescription Drug coverage), and Medigap (Medicare Supplement Insurance) Policy. Most people are eligible for Part A coverage without having to pay a monthly payment/premium if they or a spouse paid enough Medicare taxes while working.
Medicare Supplement Insurance
Medicare supplement insurance, also known as Medigap insurance, is designed specifically to supplement benefits provided under the Medicare program. This coverage typically pays for such things as medical care when you travel outside the U.S., additional expenses when Medicare coverage ends, and the difference, if any, between the “reasonable payment” provided by Medicare for a physician’s services and the amount actually charged by the physician.
Medicare copayment in 2024
In 2024, the patient is responsible for a one-time deductible of $1,632 for hospital stays of 60 days or less. For longer hospital stays, the patient’s copayment increases to $408 each day for stays between 61 and 90 days. Finally, Medicare charges a copayment of $816 each day for additional days taken from the 60-day reserve that a patient can only use once in his or her lifetime.
Coordination of Benefits
A policy with a coordination of benefits provision is one that may not pay or will pay only a portion of its benefits, if another policy is available to cover the loss. The clause prevents an insured from collecting more than needed to provide indemnity.
Medicaid
Medicaid is a joint federal and state entitlement program that pays for medical assistance to certain aged, disabled, or blind individuals, as well as children and families with low income and resources.
Health Maintenance Organizations (HMOs)
Employers may also choose to offer plans from Health Maintenance Organizations (HMOs).The Health Maintenance Act of 1973 (as amended) dramatically increased the use of HMOs. Unlike insurance indemnity plans, these arrangements usually provide for a Primary Care Physician (PCP) who coordinates care and can direct the patient to other specialists.
COBRA
Your employer has 44 days from your last day of work or last day of insurance coverage (whichever is later) to send out COBRA information. You’ll have 60 days to enroll in COBRA—or another health plan—once your benefits end. But keep in mind that delaying enrollment won’t save you money. COBRA is always retroactive to the day after your previous coverage ends, and you’ll need to pay your premiums for that period too. One advantage of enrolling right away is that you can keep seeing doctors and filling prescriptions without a break in coverage.
COBRA Eligibility
COBRA is eligible for only companies with more than 20 employees.
COBRA is also not eligible to employees who have been fired due to gross misconduct.
