Health Insurance (Chapter 3) Flashcards
At what age can a person obtain government provided health insurance from the Medicare System?
65
Paid for by payroll tax deductions during the participant’s working career and covers hospital costs.
Medicare Part A
Paid for by payroll tax deductions plus a monthly premium from SS benefits, covers medical costs: doctor’s bills, lab tests, etc.
Medicare Part B
How much do medicare households spend on health care versus non-medicare households?
Medicare Households: 14% to Healthcare Related Expenses
Non-Medicare Households: 6% to Healthcare Related Expenses
How is the Amount Subject to Coinsurance Calculated?
Expenses incurred - Deductible paid = Amount subject to coinsurance
How are total expenses due calculated on an insurance claim with deductibles and copay?
Deductibles + (Copay * Percentage owed by family/individual) = Amount Paid
With this type of deductible, insureds must satisfy the entire family deductible amount before the policy will help pay for any individuals medical expenses.
Non-Embedded Deductible
Qualified Health Plans include a provision that places a cap on the amount that the insured will be called upon to pay during any one calendar year. The cap on an insureds payments may be called _____________.
MOOP - Maximum-Out-Of-Pocket (typically includes the deductible along with copays and co-insurance. Does not include premium payments.)
What was the MOOP Limit in 2022 for individuals and family?
For Individuals - No higher than $8,700
For Families - No higher than $17,400
To meet the definition of a Qualified Health Plan, all health insurance plans sold on or off the exchange must meet ACA guidelines for cost sharing and must cover these 10 essential health guidelines:
1) Outpatient services (doctor visits, tests outside of hospital)
2) Emergency Services
3) Hospital Stays
4) Pregnancy and Baby Care
5) Mental Health, substance abuse, including behavioral health treatment
6) Prescription Drugs
7) Rehab (accident, injury, developmental issues)
8) Lab tests
9) Preventative and Wellness Services
10) For children only (dental and vision)
Individuals exempt from minimum essential healthcare coverage mandate include (these 8 types):
1) Religion
2) Members of healthcare sharing ministry
3) Those unlawfully present in U.S. (those who are not citizens or nationals)
4) Incarcerated Individuals
5) Individuals with no affordable coverage
6) Indians
7) Household income below filing threshold
8) Individuals with hardship exemption certification
(Poor, Incarcerated, Indian, Illegal, Religion)
At what point can a family or individual qualify for Medicaid?
If income is below 100% of the Federal Poverty Level for the taxpayers family size
When are individuals eligible for Special Enrollment Period?
1) Loss of eligibility from other coverage
2) Addition of Dependent
3) Divorce
4) Loss of dependent status
5) Moving to another state outside of service plan area
6) Exhaustion of COBRA plan coverage
7) For those enrolled in marketplace plan if income changes enough to change families eligibility for subsidies
What are the 4 “metal” tiers of qualified health plans and what percentage do the plans pay the actuarial equivalent of of the estimated costs of health services?
1) Bronze Plan - pays the actuarial equivalent of 60% of estimated costs of health services
2) Silver Plan - pays the actuarial equivalent of 70% of estimated costs of health services
3) Gold Plan - pays the actuarial equivalent of 80% of estimated costs of health services
4) Platinum Plan - pays the actuarial equivalent of 90% of estimated costs of health services
How many employees must a company have to be considered a large employer?
At least 50 people
What age of children are considered eligible dependents for health insurance purposes?
Children under age 26
The document that tells participants how the plan operates, what benefits are provided, and how to file a claim.
Summary Plan Description (SPD)
Under this act, eligible employees can continue group health insurance, are entitled to 12 weeks of unpaid leave for the birth of a child, adoption of a child, to care for a family member with a serious health condition, or a health condition of employee
Family Medical Leave Act
What are the tax consequences of healthcare expenditures for someone under an employer health insurance plan?
- Cost of plan does not count as taxable income to the employee
- The employer can deduct the cost of the healthcare plan
- The employee can not deduct the premiums paid because the do not count as income
The sum of the deductible and the insureds portion of the co insurance up to…
Out of pocket maximum
For comprehensive medical coverage policies after the deductible amount has been met, the insurance company pays a percentage of the medical costs and the insured pays the remainder known as the ____________ amount.
Coinsurance
Randy has medical insurance with a $250 deductible and 80% / 20% coinsurance provision with annual out of pocket maximum of $2500. The surgery costs $25,000 what will be the resulting amount owed by Randy?
Randy will pay $250 deductible and 20% of the cost of surgery in excess of the deductible up to his out of pocket maximum (ie. 20% of $24,750 = $4,950 but Randy will only have to pay $2250 + $250 deductible)
This type of coverage pays for the costs of medical care while the insured is in the hospital (services performed outside of the hospital are not covered)
Hospital expense insurance (typical policy limits are 60, 90, or 180 days)
This insurance provides coverage for fees charged by physicians for office visits and tests that are not performed in the hospital.
Physicians Expense Insurance
Pays for surgeon’s fees when a surgical procedure is not conducted in a hospital.
Surgical expense insurance
Most flexible type of health insurance policy, usually with the highest premiums in order to provide flexibility in choosing ones own health care provider.
Indemnity Health Insurance
This type of insurance can be considered restrictive when it comes to choice of health care providers. Often requires pre-approval for treatment not considered emergency care.
Managed Care Insurance
