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Disability Insurance > Medical Plans > Flashcards

Medical Plans Flashcards

1
Q

Basic Medical Expense Insurance is what?
What’s are the details of this policy?

A

Medical, hospital and surgical benefits
No Deductible (first dollar coverage)
Low dollar limits
No protection for financially disastrous expenses

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2
Q

Fee for service vs Prepaid plans ?

A

Receive payment for each service
&
Regularly even if no service provided

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3
Q

Specified Coverage ?

A

Limit coverage to one illness or one limiting group of coverages
Cancer policies, drug coverage dental
Stand alone or complementary major med exp policy

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4
Q

Comprehensive Care covers what?

A

Most types of medical expenses
Outpatient services
Hospitalization
Health care services
Preventative, immunization

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5
Q

Major Medical Insurance (Indemnity Plans) serves what purpose ?

A

Provide protection against catastrophic loss.
Uses deductibles and Coinsurance

Doesn’t respond to small claims

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6
Q

Major Medical expense contracts are characterized by :

A

High Maximum limits, Blanket coverage, Coinsurance, a Deductible

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7
Q

Another name for Major Medical Plans

A

Covered or Eligible Expense Plans

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8
Q

Major Medical Insurance Exclusions ?

A

Cosmetics
Custodial Care
War, suicide, dental vision hearing

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9
Q

Major Medical policy premium vary depending on ?

A

Deductible,
Coinsurance percentage,
Stop loss amount,
Max amount of benefit

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10
Q

Major Med Ins: if deductible is high ?
If it’s low ?

A

Lower premium
Higher premium

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11
Q

Coinsurance serves what purpose ? What are the percentages?

A

Keep costs down by requiring insured payments
90/10 80/20 70/30 50/50

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12
Q

What is a stop loss feature?

A

Amount insured pays out of pocket in a year.
Once stop loss is reached, insurer covers 100%

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13
Q

The higher the stop loss the lower/higher the premium?

A

Lower

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14
Q

What is the purpose of the impairment (exclusion) rider?

A

Eliminate coverage for a specific pre existing condition
Only means of purchasing coverage

No extra cost

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15
Q

Health Maintenance Organizations (HMOs) serve what purpose?

A

Provide benefits in the form of services
Preventative care
Provide financing and patient care

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16
Q

HMOs are offered to who?

A

Those living within a specific boundary

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17
Q

Do HMOs have deductibles ?

A

No, rather copayment

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18
Q

What is meant by HMOs operating on a capitated basis?

A

HMO receives flat rate attributed to ea member (prepaid) money ready to go

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19
Q

Goals of HMOs?

A

Reduce costs of health care by
Utilizing preventative care.
Free annual check up
Free low cost immunizations

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20
Q

HMO provides ?

A

Inpatient hospital care in or out the service area

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21
Q

Basic benefits of HMOs?

A

Hospital inpatient
Physician
Outpatient medical
Preventive
Urgent care
Emergency care
Diagnostic lab / Out of area

22
Q

HMO Supplemental service Benefits include ?

A

Long Term Care
Nursing Services
Home Health Care
Prescription Drugs
Dental care
Vision care
Mental health care, substance abuse

23
Q

Preferred Provider Organization PPO explained?

A

Traditional med system
Paid for service

24
Q

PPOs differ from HMOs how?

A

Don’t provide care on prepaid basis
Subscribers not required to use doctors on list
Reduced fee

25
Q

Which is more flexible between In Network & Out of Network providers ?

A

In network providers are more flexible

Out of network have higher costs

26
Q

Point of Service is what ?

A

Combo of HMO & PPO plans
different choose of plan can be made as need arises

27
Q

Limited Health Insurance does what ?
How is this paid ?

A

Cover specific accident or sickness limited perils and amounts of coverage

Paid on expense paid basis, indemnity

28
Q

Accidental Death and Dismemberment (AD&D) explained ?

A

Ride or separate policy
Usually group life or group health
Benefits in event of loss death or dismemberment

29
Q

AD&D pays principle or capital sum for accidental death ?

A

principle

30
Q

AD&D pays capital sum if what?

A

Loss of sight or accidental dismemberment
A percentage of the principle sum

31
Q

AD&D will pay benefits as long as death cause by accident occurs in how many days ?

A

90 Days

32
Q

What is hospital indemnity?

A

Daily, weekly, monthly payments while confined in a hospital.
Hospital fixed rate policy
Based on number of days

33
Q

What is a Specified Dread Disease?

A

Specific diseases:
Cancer or heart
Hospital confinement or chemo

Paid scheduled fixed amt

34
Q

What is a critical illness policy?

A

Multiple diseases
Heart attack, stroke, renal failure
Lump sum
Min number of days insured must survive after diagnosis

35
Q

What is a managed care plan?

A

HMOs PPOs designed to control costs by controlling behavior of participants

36
Q

What is prospective review ?

A

Submit claim info to see if procedure is covered ?

37
Q

Concurrent review is what ?

A

Insurance company will monitor stay to make sure staying to plan

38
Q

What does Health Insurance Portability and Accountability Act
HIPPA do ?

A

Regulates Protection for:
Group health
Individual policies.

39
Q

HIPPA cannot establish eligibility using which type of factors ?

A

Health

40
Q

HIPAA eligibility requirements?

A

63 days to apply
18 month’s continuous creditable health Group plan most recent
Used COBRA
Not eligible for Medicare or Medicaid
No other health ins

41
Q

Creditable Coverage means what?

A

Insured given day for day credit for previous health coverage against application of preexisting condition exclusion period

42
Q

ACA mandated providers bring what to the public?

A

Increased preventive Education
And community based health care

43
Q

The Affordable Care Act, ACA designed to ?

A

Prevent denials
Pre existing coverage
Keep premium low
Stabilize budget
Set up new competitive private health insurance market

44
Q

If someone has Medigap (Medicare Supp) they cannot be eligible for ?

A

Medicaid
To use the marketplace to by insurance

45
Q

ACA insurers 4 standard ls to base ratios for premium rates ?

A

Family composition
Age
Geo Rating Area
Tobacco

46
Q

ACA essential benefits ?

A

Hospitalization
Maternity
Emergency services
Wellness and preventive services
Chronic disease manage

47
Q

Metal Levels of ACA coverage ?

A
  1. Bronze 60%
  2. Silver 70%
  3. Gold 80%
  4. Platinum
48
Q

Catastrophic plans offer what as for premiums and deductibles?

A

Lower premium
Hugh deductible (thousands)

49
Q

What age are catastrophic plans available?

A

Adults under 30
Can’t get affordable coverage

50
Q

Under ACA premium discounts maybe awarded to who ?

A

Low income individuals regardless of metal level

51
Q

ACA offers tax deduction or credit for premiums ?

A

Credit

Disability Insurance (9 decks)

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