Health Insurance Flashcards
Termination of the employee (involuntary or voluntary for reasons other than gross misconduct) or conversion to part-time status - Period of Coverage
18 months of continuation coverage from date of qualifying event
Death of covered employee - period of coverage
36 months (for spouse and/or dependents)
Divorce or legal separation of covered employee - period of coverage
36 months (for spouse and/or dependents)
Loss of dependent status (ex. child reaching dependency age limit under employer plan) - period of coverage
36 months (for dependent)
Covered employee becomes eligible for medicare - period of coverage
36 months from the employee’s Medicare eligibility date at age 65 (for spouse and/or dependents)
Employee meets social security definition of disability - period of coverage
29 months from when meeting definition as determined by Social Security Administration
After employer notifies employee of qualifying event (ex. termination, disability), how long does recipient have to make election to continue benefits under COBRA?
60 days
Small Business Health Options Program (SHOP)
- open to employers with fewer than 50 full-time equivalent employees
- employer can control coverage its offering and how much they’ll pay towards employee premiums
- sole proprietors or those covering just themselves & family members are not eligible
Medicaid or Children’s Health Insurance Program (CHIP)
- Medicaid is a gov’t insurance program for persons of all ages whose income and resources are insufficient to pay for health care
- primarily administered and partially funded at state level
- provides health care coverage to children, pregnant women, parents, and disabled individuals with low incomes
- national Medicaid minimum eligibility level of 133% of fed poverty level for all Americans under age 65
Medicaid Eligibility
- starts retroactively for up to 3 months before month of application and stops at end of month in which no longer meets requirements
- must satisfy state & federal requirements re: residency, immigration, etc.
- Must pass asset test - assets that count include: bank & financial account, CDs, real property (other than primary residence), and additional auto (if more than one)
- Asset test does not include: primary residence, personal property & household belongings, 1 motor vehicle, life insurance w/ face value under $1,500, up to $1,500 in funds set aside for burial, certain burial arrangements
Medicaid Benefits
- most health care costs (including custodial care in nursing home)
- Medicaid required to pay Medicare premiums, deductibles, and coinsurance
- coverage for long-term care (LTC)
Medicaid Lookback Period
- Lookback period of 60 months for assets transferred to others (usually adult children) designed to impoverish donor to become eligible for medicaid
- if transfer made within 60-month lookback period, applicant is ineligible for Medicaid benefits for length of time equal to amount transferred divided by monthly cost of nursing home care for region
Children’s Health Insurance Program (CHIP)
Federal program administered by states
- Provides health insurance to children in families who do not qualify for Medicaid. Typically, CHIP benefits are applied for at same time as Medicaid benefits
Health Care Plan Internal Limits -
- In form of excluded treatments or in form of controls that limit the extent to which certain benefits may be used and paid for by the plan
- Ex. Joshua’s health plan limits the number of chiropractic visits in a calendar year, specifies the number of days of inpatient care that will be provided for mental and nervous conditions, and requires that certain surgical procedures be performed on an outpatient basis.
Health Care Plan - Exclusions
- If expense is not specifically excluded, it is eligible for reimbursement.
- Expenses incurred as a result of using products or services that are not covered do not count towards meeting deductible or coinsurance requirements
Pre-Existing Conditions
-PPACA eliminated pre-existing conditions except for grandfathered individual health insurance policies
Utilization Review
- Pre-certification (form of utilization review) usually required when hospitalization is recommended, and common for diagnostic tests such as MRIs or higher cost meds.
- Attempt to control costs of health care
- ex. getting second opinions, reviewing plans, etc.
Case Management (form of utilization review)
- another form of utilization review
- used to control costs and optimize patient benefits in treatment of expensive illnesses (ex. diabetes, cancer, etc.)
- Health care plan’s medical staff is involved from outset of setting up long-term treatment plan
Coordination of benefits for working couples
- One is considered primary and primary plan pays benefits up to its limits first; secondary pays up to limit for costs not covered by primary plan
- Determining which is primary can be complicated; one holds that primary coverage comes from parents whose birth (month and day) comes first in year, other method is gender (father’s plan)
Deductibles
A separate deductible may apply to each person covered by the policy, usually with a maximum number of deductibles (or a maximum dollar amount) per family.
More recently, some policies have added a separate hospitalization and/or emergency room deductible to the standard major medical deductible. Each of these deductibles is an attempt to reduce the use of expensive treatment options when other options may be available.
Copay
- Cost sharing technique started by HMOs of a fixed fee foreach visit; paid regardless of services rendered.
- Applied to deductibles or maximum out-of-pocket limit
Coinsurance
Applies to covered expenses until insured has reached max out-of-pocket expense limit (ex. 80/20 - or 20% for insured - until MOOP limit met)
Maximum Out-of-Pocket (MOOP) Limit
- Limit insured will pay out of pocket for care.
- MOOP limit only applies to approved charges
- If plan allows insured to go out of network, but pays a lower percentage, the additional amount insured is responsible for is not included in MOOP calculation
Prepayment plans
Managed care plans where payments for services are negotiated and paid to health care providers. Primary care doctor receives capitation fee to take individual as patient; as result, pool of available doctors is limited
Indemnity (Postpayment) plans (aka fee-for-service plans)
- Pay for covered expenses once they are incurred
- Plans where client has total choice of providers w/out payment discrimination because insurance company is indemnifying covered persons and reimbursing them for covered expenses
Comprehensive Major Medical Policy
Indemnity policy that incorporates essential medical services under one plan.
Daily Benefit Plans
Another type of indemnity plan typically offered by specialty providers that pays a daily benefit (or fixed dollar) amount when the insured is sick, in the hospital, or disabled. Premiums are based on the chosen benefit amount. These plans do not really provide medical expense coverage—they are ancillary or supplemental benefit plans that pay the insured a benefit once a specific trigger event has happened (e.g., the insured enters a hospital). While there is a benefit for these plans, they do have a potential downside in that some insureds may mistakenly believe they have purchased a true medical expense reimbursement plan, when they actually have limited coverage only under specific circumstances.
Managed Care (Prepayment) Plans
- Include HMOs, PPOs, POS plans, EPOs, and PSNs.
- Individuals covered are called subscribers or members vs. insured.
- Managed care plans control cost of health care through various mechanisms (ex. salaried providers, capitation, negotiated fees, etc.)
Capitation
Assures primary care physician (PCP) is paid fixed fee for every health care plan subscriber who names physician as patient’s PCP. Then provides whatever services patient needs.
