Medical Expense Insurance Flashcards
Medical expense insurance
Basic hospital, surgical and medical policies and major medical policies are grouped into medical expense insurance.
Do hospital, surgical and medical coverages require a deductible?
No, they usually do not require the insured to pay a deductible
Basic hospital expense coverage
Hospital expense policies cover hospital room and board, and miscellaneous hospital expenses, such as labs, x-rays, medicines, use of operating room and supplies, while the insured is confined in a hospital.
Miscellaneous hospital expenses
Normally have a separate limit. They pay for other miscellaneous expenses associated with a hospital stay
Basic medical expense coverage
It provides coverage for non surgical services a physician provides. However, the benefits are usually limited to visits to patients confined in the hospital.
Basic surgical expense coverage
This is commonly written in conjunction with Hospital expense policies. This policy pays for the costs of surgeons services, whether the surgery is performed in or out of the hospital. It includes surgeon fees, anesthesiologist and the operating room when it is not covered as a miscellaneous medical item
Comprehensive major medical
Is a combo of basic expense coverage and major medical coverage, sold as a separate policy. They do include a deductible.
In an HMO, a gatekeeper helps control what?
Helps control the cost of healthcare by only making the necessary referrals
Point of service (pos) plan
Is a combo of HMO AND PPO PLANS. Individuals can visit an in-network provider at their discretion and an out of network physician.
Medical savings account (MSAs)
Is an employer funded account linked to a high deductible medical insurance plan. They are only available to small employers with 50 or fewer employees, or a self-employed person. The employer raises the medical plan deductible and returns all or part of it to the employees to contribute to the MSA. The employee uses the funds from the MSA to cover health insurance deductibles during the year. If there is a balance at the end of the year, the employee may leave it in the fund to collect interest or withdraw the remaining amount as taxable income.
Flexible spending accounts (FSAs)
Is a form of cafeteria plan benefit funded by salary reduction and employer contributions. The employee deposits a certain amount of their paycheck into an account before paying income taxes. During the year the employee can be directly reimbursed from this account for eligible health care and dependent care expenses. It is a use or lose annually. Changing can be made during open enrollment unless the circumstance are deemed a qualified event. They are tax exempt.
Grace periods
In most cases the grace period for policies due on a weekly bases is no less than 7 days, 10 days for monthly premium policies and 31 days for all other modes. Coverage will continue in force during the grace period
What is Group underwriting
It’s designed to avoid adverse selection by the following requirements:
The insured must be incidental to the group
There should be a steady flow of persons through the group
The persistency of the group
A method that prevents the individual selection of benefits
Eligible participants
Size and composition
COBRA (consolidated omnibus budget reconciliation act)
Requires any employer with 20 or more employees to extend group coverage to terminated employees and their families after a qualifying event.
Qualifying COBRA events are
Voluntary termination of employment
Termination of employment for reasons other than gross misconduct
Employment status change: full vs part time
