Health Insurance Flashcards
this is also called accident and sickness insurance and other times ____ and ____ insurance
Health insurance… accident and health
at its beginning, the original purpose of health insurance was to indemnify (reimburse) insureds for ____
just risk type expenses
the purpose of health insurance is to protect an insured agains the risk of financial loss he/she cannot individually afford caused by ___, ____, or _____
injury illness disability
Indemnity means ____
reimbursement
both the principle of _____ and ____ ____ prohibit the insurance company from reimbursing an insured for more than the actual amount of the loss
indemnity, insurable interest
a provision that is included in some policies. it allows insurance companies to reduce benefits so that the insured will be paid no more than his/her actual loss. it prevents the insured from collecting under multiple policies more than his or her actual loss.
coordination of benefits provision
a policy that includes a coordination of benefits provision
coordinating policy
a policy that does not include a coordination of benefits provision
non coordinating policy
basic principles of the affordable health care act (ACA)
a. ACA requires that all people under age __ who are in the US legally to have hospital/medical expense reimbursement insurance
b. ACA applies only to hospital/medical policies for people under __
c. it does not apply to disability income, hospital income, limited disease, accidental death and dismemberment, medicare supplement, medicare advantage or long term care policies
65
expense reimbursement pay only the insured’s _____ hospital/medical expenses. expense reimbursement usually include a coordination of benefits provision
actual
stated benefit (stated value) policies pay a ___ or ___ benefit (value) independent of and unrelated to actual hospital or medical charges.
- usually do not include a coordination of benefits provision
- usually non coordinating
stated or fixed
benefits to which an insured is entitled under a coordinating expense reimbursement policy will ______ by benefits to which the insured is entitled under a non coordinating stated value policy
not be reduced
benefits to which an insured is entitled under a non coordinating stated value policy will be ____ in addition to benefits to which the insured is entitled under coordinating expense reimbursement policies
paid
a coordinating policy can coordinate only with another ___ policy
coordinating
an individual’s group health insurance benefits through his or her employment will be their ___
primary coverage
if an individual has a primary insurance and their spouse has coverage as well, it is known as ____ or ____ coverage
excess or secondary
both individual and group hospital/medical expense reimbursement insurance policies usually exclude expenses covered by ____ _____ insurance
workers compensation
Medical information bureau Report
is a _____ for medical information for insurance companies that belong to it
clearinghouse
Tax treatment of health insurance premiums and benefits
- premiums on individual hospital/medical expense policies can ____ be tax deducted
a. it depends on whether the individual is self employed or employed by someone else
b. it also depends on whether the individual itemizes on their tax return - premiums usually cannot be tax deducted (___)
- there is usually no tax on the benefits (___)
- premiums and policies paid by the employer can be tax deducted by the employer (____)
- there is usually no tax on benefits on group health coverage (tax free)
- there is usually tax on benefits on group disability coverage
sometimes
non qualified
tax free
tax qualified
Private health insurance companies
a. primarily offer ___ and ___ plans. there were originally established to issue risk indemnity policies
b. private health plans cover primarily ___-type expenses
c. these typically have the ___ restrictions to where the insured can go for service
HMO, PPo
risk
fewest
Service organizations
a. blue cross was originally established as a non-profit service organization to assure the payment of _____ charges. blue shield was originally established as a non profit service org to assure payment of ___ charges
b. the covered member, who is called a ____, pays a monthly subscription fee
c. the subscriber is entitled to obtain hospital/medical services from any hospital or doctor provide that is a ___ of the service org network
d. if the subscriber were to go to an out of network provider, will they be covered?
hospital, physician’s
subscriber
member
no
A PPO is an organization that organizes groups of hospitals and physicians to provide medical services at _____ ____ ___
negotiated discounted
Insurance companies encourage their insureds to stay in the network but allowing their insureds lower ____ and ____ requirements to apply if they stay in network
deductibles and coinsurance
if they go out of network, higher ____ and ____ requirements will apply
deductibles and coinsurance
HMOs provide a list of ____ ___ ____ that are usually similar to major medical benefits
specified health services
the covered individual is entitled to obtain medical services from ____ or ____ service providers that are part of the plan networks
hospital, physician
HMO’s put the ____ limitations on where the insured can go for service
most
HMOs provide the most liberal benefits for non risk type expenses such as ____, ___ ____ and other forms of preventative medicine
physicals, wellness programs
HMOs provide the ____ premium rates of the various types of health insurance organizations
lowest
HMOs practice ____ ____ to the greatest extent of any insurance organization
managed healthcare
insurance organizations have many ways of managing health care of their insureds. their objective is provide proper, effective ____ ___, while at the same time, containing ___ and avoiding unnecessary ____
health care, costs, services
although managed healthcare is practiced to some extent by all types of insurance organizations, it is mostly associated with ___ ____ ___
HMOs
HMOs usually provide guidelines to their network hospital and physician service providers as to what care and how much care is ____, ___ and ____ for each particular condition
reasonable effective efficient
the primary care physician is aka as what
the gatekeeper
HMOs sometimes compensate their network hospital and physician service providers on a ____ __ basis.
capitated fee
capitated fees provide the service provider with a ___ ____ to avoid unnecessary treatment and to contain ___
financial incentive, cost
Point of service plans are issued by?
HMOs
due to the high level of managed health care practiced by the HMO for in network treatment, the insured receives a ___ premium rate compared to private insurance risk indemnity plans
lower
the insured also has the benefit of being able to go to hospital/medical service providers that are outside of the HMO network with ___ deductible and coinsurance requirements applying
higher
private insurance company risk indemnity plans, BCBS provides service plans, PPO and HMO plans usually ____ benefits by benefit amounts to which the insured is entitled to coverage under the federal and state gov insurance programs
reduce
when one plan reduces benefits by benefit amounts to which the insured is entitled up coverage under another plan, it is called ____ ____
coordinating benefits
Workers comp insurance is a type of _____ insurance, not health insurance
casualty
private insurance company risk indemnity plans, BCBS service plans, PPO plans and HMO plans usually ____ expenses covered by workers comp insurance
exclude
when one plan excludes coverage for expenses covered under another plan, it is referred to as ______ ___
coordinating benefits
when after an insurance organization pays a claim, it becomes entitled to the insured’s rights to make a claim against another insurance org to recover the benefits they have paid
subrogation
insuring too many health conditions insureds have before the policy is issued, causing premium rates to be inadequate to pay claims. two policy policy provisions that insurance companies use in health insurance to avoid ____ ____ are pre-existing conditions clauses and impairment riders
adverse selection
pre-existing condition clauses and impairment riders may not be used only in policies that do not come under the ___ ___ ____
affordable care act
it is an optional provision included in some health insurance policies to avoid adverse selection
pre existing condition clause
the furthest an insurance company can go in classifying a condition as pre existing under the pre existing condition clause is
two years
the farthest back the pre existing condition clause is
two years
what does manifested mean?
made clear
an optional provision included in some policies to manage adverse selection
a. it excludes a particular health condition, or group of health conditions specifically
impairment rider - only in individual policies
the purpose of ____ expense insurance is to protect insureds against the financial risk of illness or injury expenses that cannot individually afford
hospital/medical
hospital expense coverage
pays benefits for only hospital expenses such as ___, ___ or ____ may apply
deductibles, coinsurance, and or copayments
benefits that pay for hospital room, board, general nursing care and other routine services. per day and maximum (____) limits apply
daily hospital benefits, aggregate
benefits that pay for hospital laboratory, x ray, anesthetic, operating room and medicine and dressing expenses. limits are expressed as a multiple of the daily hospital benefits
miscellaneous hospital expense benefits
pays for hospital surgical procedures specified in the policy as well as any other of the insured may be required to have. Benefits can be expressed either according to a surgical schedule or a surgical relative value table. Insurance company will pay 100% of major procedure and 50% of the minor procedure
surgical expense benefits
pays doctor charges incurred in the hospital and sometimes after being discharged for conditions treated in the hospital
physicians expense benefits
this can be used as a separate policy by itself or along with Hospital Expense coverage
major medical coverage
major medical coverage ___, ___, and ____ ____ hospital and medical expenses to include:
A. hospital expenses not covered by hospital expense coverage
B. hospital out-patient expenses
C. doctor office expenses
D. major medical coverage sometimes covers prescription drugs. Other times its a separate coverage
usual, reasonable, and customary eligible
A. insurance organizations survey health care providers to determine what the normal range of fees charged for specified services is for each region in which the insurance organization issues policies.
B. most policies cover only expenses that do not exceed what the insurance organization has determined to be reasonable and customary.
usual, reasonable, and customary charges
are charges for services that are covered under the insurance policy
eligible expenses
A. the insurance company pays a percentage of usual, reasonable, and customary eligible expenses. The insured pays the rest until the deductible
B. the stated level of eligible expenses where the insurance company begins indemnifying 100% of the insured’s expenses, and where the insured’s losses stop, is called a stop loss
policyholder participation/ coinsurance
is the maximum the insured will be required to pay under both the deductible and coinsurance requirements
maximum out-of-pocket
a small specific deductible amount that the insured must pay before the insurance company begins to indemnify for a particular type of expense
co-payment
the purpose of the ___, ___, and ___ ___ requirements is to encourage the insured to avoid unnecessary expenses and to eliminate small claims that the insured can afford and which would cost the insurance company to administer
co-payment, deductible, and policyholder participation/ coinsurance
major medical always has a high limit of liability. no annual of lifetime limits of liability apply to the ACA. qualified health plan
high limit of liability
are covered only if required as a result of an accident
cosmetic and dental surgery
taxation of premium and benefits of health insurance
A. premiums on ___ hospital/ medical expense coverage ___ can be tax deducted by the insured
B. premiums paid by an employer on ___ hospital/medical expense coverage usually can be tax deducted by the employer (___)
C. there is usually ___ tax on individual or group hospital/ medical expense benefits
individual, sometimes
group tax qualified
no
programs through which hospital/ medical expense plans are issued:
- HSA
- MSA
- HRA
- FSA
- Health savings accounts
- medical savings accounts
- health reimbursement accounts
- flexible spending accounts
a. are accounts that can be established by an individual, family, or any size employer to cover hospital/medical expenses not covered by a high deductible health plan
b. high deductibles apply on the health insurance coverage
c. part of all of the deductible can be contributed annually to a health savings accounts
d. contributions to health savings accounts are usually tax deductible
e. HSA balances carry over to the next year
health savings accounts (HSA)
are very similar to HSA. they are available only employers of certain sizes
medical savings accounts MSAs
Twelve ____ uniform policy provisions that are required in all ___ accident and health insurance plans
required, individual
First required uniform policy provision
- only includes whats in the contract
- no change is official until it is signed by an officer of the insurance comp
entire policy - changes
2nd required provisions
- pre existing condition clauses
- incontestability - proving fraud
time limit on certain defenses - incontestability - 2yrs
3rd provision
7, 10 and 31 days
grace period
4th provision
45 days, 10 day waiting period - illness claims
reinstatement
5th prov.
- notice of loss - 20 days
notice of claim
6th prov
-15 days from notice of loss
claim forms
7th prov
- 90 days from notice of loss and every 6 months
proof of loss
8th prov
time of ___ of claims - immediately and no less often than monthly
time of payment of claims
9th prov
____ of claims
payment
10th prov
Physical examination and ____
autopsy
11th prov.
- ____ actions - 60 days, 3 years
legal actions
12th prov
change of ____
beneficiary
the clause that states the insurance company’s promise to indemnify
the insuring clause
children must be allowed to be covered as dependents under their parent’s policy through age 25 until their age 26 bdays
dependent coverage
______ clause
a. a transfer of one of more rights in a policy to another
b. the policyowner has the right to assign benefits of a policy or ownership of a policy to another
c. ins co will not be responsible for the validity of the assignement
assignment
Renewability provisions
- _______ renewable
a. the policy is renewable at the ins co’s option
b. the insured has no guarantee that the policy will be renewed - ______ renewable
a. ins co can refuse to renew only for reasons stated in the policy - ____ renewable
a. ins co must renew
b. ins co can change rates only by class
c. all hosp/med policies covering people covering people under age 65 which come under the ACA must be guaranteed renewable - ____ and _____ renewable
a. ins co must renew
b. ins co cannot cancel the policy
c. premium rates cannot be changed at all
d. this is found only in stated value policies
optionally
conditionally
guaranteed
noncancelable and guaranteed
if included it excludes disabilities caused by injuries sustained while on active duty in the armed services
injuries while in armed forces
most apps ask if the insured flies or intends to fly as other than a fare paying passenger on a commercial airline within two years. if the insured does, they can choose either a rating or an aviation exclusion. if the aviation exclusion is chosen, then the insured will not be covered while flying other than fare paying passenger on commercial airline
injuries in aircraft
policies that come under the ACA must cover maternity expenses
pregnancy
mental infirmity
psychological or psychiatric couseling
a. an insured is a ____ ____ if they are at least 18, not on drugs or drunk, and has not been adjudicated mentally incompetent before buying the policy
b. if not, the policy is voidable by the insured
competent parties
it promises to pay (indemnify) subject to conditions (requirements) being met at the time that the policy is purchased and at time of the claim
conditional contract
once the conditions are met, only one party is required to perform (ins co)
unilateral contract
one party, the ins co, writes the contract and determines the terms. the other party, the insured, accepts or rejects the contract and terms that the ins co has written
contract of adhesion
