Hl Flashcards
Injured
Offers comprehensive prepaid health care services its subscribing
Hmo
Subscribers pay a fixed periodic fee
Hmo
Pays a fixed periodic fee
Hmo
What is a hmo
Health maintenance organization
Payment given to physician is called
Capitation
Stressing preventive care
Hmo
Self funded based on dues or fees from their subscribers contact excess insurance
Hmo
Employers with 25 or more
Hmo
What is a ppo
Preferred provider organization
Collection of health care providers at prearranged discounts
Ppo
Fee for service rendered
PPO
Fee for service rendered
PPO
Specialize in one or more types of medical expenses and disability income insurance
Commercial insures
● Life insurance
● casualty
● monoline
Functions on the reimbursement apporach
Life insurance
Casualty
Monoline
Let’s policyholders assign benefits payments from insurer directly to health care providers
Assignment
What relieves the policy owners of first having to pay the medical care providers
Assignment
Delivers health services at its own local health care facilities subscribers
HMO
pay a fixed periodic fee
HMO
Physician that work out of the HMO facility
CLOSED PANEL
Physician who work out of their own facilities participate in hmo part time
HMO IPA
requre subscribers to select a primary care
HMO
Groups at prearranged discount prices
PPO
made in 1966 provide hospital and medical expense
MEDICARE
What’s part A
drug administration Insured enters a hospital benefit 100 days period in a skilled nursing 1-20% 21-100 flat dollar amount per day 190 days inpatient psychiatric Primary source of financing federal payroll self employment taxes
Jan1 mar31 funded by General tax revenue and user premiums
Part B
Covers inpatient hospital stay
PART A
Financial protection against the cost of medical care for accidents and illness
MEI
Excludes cove6 for care provided in a government facility written for a term of 1 yr
MEI
First dollar insurance
BMEP
Covers hospital room and board miscellaneous expenses
Part A
Expenses are covered while the insured is confined in a hospital
PART A
No deductible room board are set specified dollar amount per day up to # days
PART A
Utilization review that takes place on site length of stay in the hospital
Concurrent review
testing reducing length of hospitalization
Peradmission
Pays service is performed in or out of hospital
Basic surgical expense
Surgeon fee anestigist operating room
Basic surgical expense
Assigned a dollar amount by the insurer
Surgical schedule
Paid in full surgical expenses compared to what is deemed reasonable
Reasonable customary
Charges are the maximum amount the insurer will consider eligible for reimbursement
Usual customary reasonable UCR
Set of units is aggigned dollar per units conversion factor to determine the benefit
Relative value approach
Covers er accidents benefits offer only limited benefits they’re subject to
time limitations
Basic physician expense coverage
Supplement to a basic plan or as a comprehensive stand alone plan
Major medical expense
Benefits are 1 yr
Carry deductible coinsurance requirements
Have large benefits maximum
Covers inpatient and outpatient hospital expenses
Major medical expenses
Pain management home based services counseling hospice benefits
Major medical expenses
Lists if drugs covered by a pharmacy
Drug formulary
Initial stated dollar amount
Flat
Covers the gap between basic coverage and major medical
Corridor
Major medical plan is supplementing basic coverage
Integrated
Insured must satisfy a deductible for each accidental or illness
Per cause deductible
Insured only has to meet the deductible amount once during the benefit period
All cause deductible
Deductible begins January 1st ends dec31st insured must pay a specific
Sum out of pocket before any benefits are paid in a yr
Calendar year deductible
Permission expenses incurred during the 3 last 3 months
carried over into a new year to satisfy deductible for next year
Carry over
One deductible need be satisfied when 2 or more insured same
Family are injured in same accidents same illness
Common accident or sickness
Waives the deductible for family members after some deductible have been paid same year
Family maximum
Sharing of expenses by the insured and the insurer
COINSURANCE
Percentage of payment
Insured is 20%
Insurance companies 80%
Limits the amount of expenses the insured may be exposed to in a year
Stop loss
Taxable 20% penalty distribution
HSA
Tax advantage reimburse employees for out of pocket medical expenses and individuals
Health premiums
Health reimbursement arrangements HRA
Unused amounts maybe carried forward for reimbursement in future yrs
Hra
Reimbursement tax free qualified medical expenses or qualified
Medical plan
Hra
Employees don’t contribute to an
HRA
Small employers pay for their medical care expenses self employed
Medical saving account MSA
Individuals tax free account for employers 50 employees
MSA
Tax advantage accounts set up through a cafeteria plan of a employer
FSA
Allows an employee to set aside a portion of earnings to pay for qualified medical
Expenses established in the cafeteria plan
FSA
Disability defined
Insured must be totally disabled before benefits
under a disability income policy are payable
considers the insureds education,training,experience
To receive disability income benefits the insured must be unable
To work at the insured own occupation
Own occupation OC
Insured must be unable to perform any job for which
The insured is reasonably suited by reason of education
Training
Any occupation AO
Reduces or eliminate the insured ability to work
For the rest of the insured life without expectations
Of recovery
Permanent disability
Activities not limited to caring for oneself
Manual tasks
Americans with disabilities act ADA
Can’t perform the insured current occupation as a
Result of an accident or sickness
Own occupation
Less restrictive than any occupation
OC
Long term disability policy use okc clause for 1st 2 to 5
Of disability after provide benefits under an oc
Own occupation
Unable to perform any occupation
Any occupation
Policy that don’t cover losses due to hazardous occupation
Nonoccupation
Automatically gives insured fit full benefits because
The severity conditions presumes insured is totally disabled
Even if you are able to work
Presumptive disability
Can’t perform one or more important duties
Of the job can’t work full-time which results in decrease income
Partially disability
Applies to accident and illness disability
Pd
Disability resulting from one accident
Pd
Encourage disability to get back to work
Pd
Payable only if totally disabled
Pd
Insured collect 50% of the monthly income for
3 months or a 6 month
Pd
Amount of benefits payable depends on policy stipulates
A flat amount or residual amount
Pd
Disability caused by accident or illness
Illness will be coverage unless restricted
By a pre existing conditioners or policy limitation
Injury or accident vs sickness disability
Injury must have been unexpectedl and accidental
Injury or accident
Result of injury has to be unexpected and accidental
Sickness disability
Totally disabled due to accident and illness
Only collect loss of income due to accident or sickness
Injury accident sickness
Disability that occurs later amount allowed
Is 20 30 60 90 days
Delayed disability
Spec a period of time during recurrent of a disability
Is considered a continuous of prior disability
Recurrent disability
90 or 6 month benefits without new policy
After that period it’s a new disability
Recurrent disability
Subject to a new elimination period before benefits are
Again payable
Recurrent disability
Injury that doesn’t qualify for income benefits
Nondisabling injury
Must provide a proof of treatment
Nondisabling disability
Insured to stay indoor
Confining
Isn’t required to stay indoor
Nonconfined
Benefits paid under a disability income
Policy are in the form of monthly income payments
Disability income benefits
A ceiling on the amount odes disability income protection they’ll
Issue on any one applicant based on the insured income at the
Time of purchase
Disability income benefits
Compared to the insured previous earnings the benefits provided
Under di6 income insurance should be somewhat less to avoid
Over insurance
Disability income benefits
Percent of earnings approach which determines the benefits amount
By using a percentage of the insured pre disability earnings take into account
Other sources of disability income
First method
Flat amount method benefits amount if insured
Is totally disabled payable regardless of income
Received
Second method
Set amount benefits stated in the policy
Flat amount benefits
Amount is usually 50% of the full disability benefits
Flat amount benefits
Based on the proportion of income actually
Lost due to the partial disabilities taking into account
The fact that the insured is able to work
And earn some income
Residual disability amount benefits
Partial and residual disability riders may not be added to the same policy
Residual disability amount benefits
Benefits is usually determined by multiplying the percentage of lost
Income by the stated monthly benefits for total disability %x monthly
Income
Residual disability amount benefits
Gives training to prepare insured for a new occupation
Rehabilitation benefits
Insured pays benefits as long as the insured remain
Totally disabled and active in the program
Rehabilitation benefits
Benefits of 1% of the face amount of the policy
Which is payable if the insured is totally disabled
Disability benefits in a life insurance contact
Determine if an income loss has act6 occurred
Loss of earnings test
Short term income provide for an optional lump sum payment
Rather than receiving a peri9 payments for certain injury
Elective indemnity
Short term riders benefits during the first 6 to 12 months of a disability
Additional monthly benefits Amb
Waives the elimination period while the insured is con6 to a hospital
Hospital confinement rider
Purchase to help make loan payments if the insured were
To ever become disabled pay the monthly payment
Credit disability
Guaranteed renewable noncancellable exempts
The policyowner from paying the polices
Premiums during period total disability
Waiver of premium rider
Must be totally disabled for 3 or 6 months
Premiums are waived beginning at date of
Disability doesn’t extend past 60 or 65
Waiver of premium rider
Subject to income tax
Social security rider
Extends the benefits period beyond age 65
If insured is totally disabled as result of a injury
Or illness
Lifetime extensions rider
Indexing the monthly or weekly benefits payable
Under a disability policy to changes in the consumer price
Cost of living adjustments COLA
Benefits amount is adjusted on each disability anniversary date to
Reflect changes CPI
Cost of living adjustments COLA
Guaranteed the insured the right to periodically increase
The amount of benefits payable without evidence
Insurability
GUARANTEED INSURABILITY RIDER
Future increase or income option
GUARANTEED INSURABILITY RIDER
Time that must elapse following the effective
Date of the policy before benef6 are payable
PROBATIONARY PERIOD
Time immediately following the start of a disability
When benefits are not payable
Elimination period
Time based deductible in a disability income policy
Elimination period
Disability income policy include a day eliminate period
30 day
Eliminate claims for short term disability
Elimination period
Lowers the premium for comparable disability benefits
Longer elimination period
Waiting period
Elimination period
Maximum length of tine that disability income benefits will be paid to the disabled
Insured
Benefits period
Higher the cost of the policy
Longer the benefits period
Rather than charge additional premiums or exclude
Coverages
Benefits period
6 to 2 yrs benefits
Benefits period
Individual long term polices pay benefits periods
Of more than 2yrs 5 10 20 yrs to age 65
Benefits period
Shirt term disability benefits policy are paid weekly
Benefits amount
Long term disability benefits are paid monthly
With a maximum benefits limit
Benefits amount
Amounts are limited to encourage disabled
Individuals to return to work
Benefits amount
Actively working for a stated number of hrs per with
If coverage extends past age 65
Coverage after 65 provisions
Injured in a hazard occupation stated in policy
Change of occupation provision
Benefits levels are reduced
Change of occupation provision
Engaged in less hazardous occupation then originally stated
In policy benefits will likely be increased
Change of occupation provision
Refund provision for a insured for a % of all premiums
Paid certain period
Return of premium provision
Returns alk premiums to policyowner at age 65
CASH SURRENDER VALUE RIDER
Exclude losses arising from war military service attempted
Suicide overseas residence
Disability exclusion
Savings
Borrowing money from others
Depending on a partners income
Liquidate assets
ALTER9 DISABILITY INCOME
Life insurance pension or profit sharing plans vacation pay deferred
Compensation arrangements funeral sicktime
Employee benefit plans
Business owner becomes disabled individual
Business overhead expense
Rent or mortgage utilities telephone leased equipment
Employee salaries taxable income
Business overhead expenses insurance
Selling and buying a PARTNERS or stock owners share of a business
In the event of DISABILITY funded disability income policy paid
To company or another shareholder
DISABILITY BUY SELL PLANS
Benefits in the form if periodic pay9
Lump sum payments tax free
Lengthy elimination periods 2 yrs
Disability buy SELL plans
Monthly benefits to the business owner is totally disabled
To specifically payoff a loan or another fi9 obligation
Reducing term insurance
Paya9 only for the remaining period of time of the outstanding debt
Reducing term insurance
Policy owned by business insured is the owner not tax deductible
Tax free monthly benefits
Reducing term insurance
Monthly benefits to a business covers expenses for additional help or outside services
Key person
Disabled person policy elimination period will be
30 to 90 days benefits period 1 or 2 yrs tax free
KEY PERSON
Premiums paid are fully deductible not income taxable
Sole proprietors
Premiums paid are tax deductible to partnerships
Paid by partnership not income taxable
PARTNERSHIPS
Premiums paid are tax deductible and benefits receives
Not income taxable
LLC
