Health Insurance Flashcards
2 Perils
Accident and Sickness
Accident
unintentional bodily injury caused by an unforeseen event
Sickness
a need for medical care due to a cause other than an accident
Hospital/Medical Expense Coverage
helps pay doctor and hospital bills; includes coverage for diagnostic and treatment-related expenses such as lab tests, x-rays, and medical supplies (sometimes prescription drugs)
Disability Income Insurance
pays a stated amount of income to the insured when an accident or sickness leaves them unable to work for an extended period; provides money to pay other bills (aka Income Replacement/Loss-of-time coverage)
Dental Expense Insurance
helps to pay dental bills; coverage is generally provided for routine dental care such as cleanings, fillings, crowns, root canals, and braces.
Long-term-care (LTC)
insurance provides coverage for medical and non-medical care for individuals with chronic illnesses, cognitive impairment, or difficulty performing activities of daily living (ADLs) such as bathing, dressing, eating, toileting, transfering, or continence.
Individual Insurance
Anyone can apply for coverage.
Each person has a policy.
Individual can choose coverage from whatever is available in the health insurance market.
Individual’s health is evaluated; a medical exam may be required.
Coverage renewable at option of the insured, sometimes insurer.
All accidents are covered regardless of when or where they occur.
Group Insurance
Only group members may be covered; group must meet size and purpose definitions.
There is one master contract; individuals are given certificates as evidence of coverage.
Benefits are essentially the same for all group members; individuals may be able to choose among a limited number of pre-established packages.
Group as a whole is evaluated, usually no individual underwriting. (No evidence of insurability required if individual enrolls within a given time after becoming eligible)
Group sponsor may change coverage; coverage stops when insured leaves the group.
Only off-the-job accidents are generally covered (on the job accidents are covered by worker’s compensation, a state-mandated program)
TRICARE
for active duty and retired military personnel
Veterans Benefits
for discharged military service members
Medicare
healthcare primarily for senior citizens and recipients of social security disability
Medicaid
healthcare for individuals and families who are or become poor
Social Security Disability
for eligible individuals who become totally and permanently disabled.
Comprehensive Policies
offer broad coverage for health care services.
Limited Policies
provide benefits for only a particular type of loss; there are a number of special health insurance policies that provide limited coverage
Limited Benefit Plan
limited perils. limited benefits. notice to proposed insured
Limited Perils
while medical expense plans cover losses that arise from almost any cause with just a few exceptions, limited benefit plans cover losses that arise only from one peril or one type of peril, or which occur relative to a specific situation or location.
Limited Benefits
while medical expense plans have moved quickly toward providing very high or unlimited benefits, the amounts paid by limited benefit plans are typically much smaller and often restricted to stated amounts
Notice to Proposed Insured
to assure that insureds understand the limited nature of the coverage they are buying, states require these policies to contain a prominent notice on their first page stating that the coverage provides only limited benefits.
Accident-only Policies
only cover accidents as a peril, and exclude any type of sickness or disease. (Premiums are smaller than policies that cover both illness and injury) - may also pay a benefit if an accident results in dismemberment, disability, or death.
Specified/Dread Disease Policies
policies were originally developed to cover one, or one type, of catastrophic illness specified in the policy such as cancer or heart disease.
Critial Illness Policies
wider-range policies that may contain screening benefits to help with early diagnosis of catastrophic illnesses.
Hospital Income/Indemnity
pays a flat dollar amount as a daily benefit for each day that the insured is hospitalzed as an inpatient. (paid directly to the insured)
Credit Disability Insurance
a group policy with a retailer as master policyowner and the debtors are the group members.
Blanket Coverage
type of group insurance where the group members are identified as the person engaged in a similar activity (such as emplyees at a company picnic, passengers on an airplane, players/spectators at a sporting event, students on school grounds)
Prescription Drug Coverage
can be included in a medical expense plan, added as a supplement to a medical expense plan, or issued as stand-alone coverage.
Vision Care Plans
Covers eye exams, cost of lenses and frames, cost of contact lenses, and other corrective items. (Routine eye care and vision correction)
Hearing Insurance
a limited plan that provides coverage for hearing exams and some or all of the costs for hearing aids
Short-term Medical Expense plans
sold as a means of temporary health insurance coverage (90 days - 12 months)
Health Insurance Exclusions
Intentional Self-inflicted injuries. War/Act of War (excluded regardless of service in the military) . Elective Cosmetic Surgery. Workers Compensation. Commission/Attempted Felony
