Module 4 Flashcards
Health, Disability, LTC, and VA Insurance
Understanding the health insurance rights, requirements, and responsibilities that pertain to your clients through various government mandates and contract requirements is essential in your financial planning role. There are three important federal acts that form the basis of these items:
the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the Patient Protection and Affordable Care Act of 2010 (PPACA).
Although COBRA went a long way in ensuring continuation of health care for departing employees, it did not address the issue of ? when switching jobs.
pre-existing medical conditions
What is the Health Insurance Portability and Accountability Act of 1996 (HIPAA)?
It is a U.S. federal law enacted in 1996 that establishes national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.
HIPAA eliminated the previously detrimental aspects of changing jobs and enrolling in a new employer group health insurance plan that included a pre-existing conditions clause.
Specifically, HIPAA provided that there could not be enforcement of a pre-existing medical condition clause if:
an employee was covered by the prior employer’s health insurance plan for at least ?, and
fewer than ? have elapsed since the loss of coverage under the prior employer’s plan.
12 months; 63 days
What is the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) ?
A U.S. federal law that allows employees and their families to continue their employer-sponsored health insurance coverage for a limited period after losing their job or experiencing certain other qualifying events.
What act is the below blurb referring to?
In most cases, employees may maintain group health insurance benefits for up to 18 months after leaving work. Employers with 20 or more employees normally have to offer this extended health insurance coverage to terminating employees. A part-time employee counts as half an employee for purposes of this rule. Note that government and church employers are exempt from ? requirements.
COBRA
What is the Patient Protection and Affordable Care Act of 2010 (PPACA)?
Commonly known as the Affordable Care Act (ACA) or Obamacare, is a U.S. federal law enacted in 2010 to expand access to healthcare, improve the quality of care, and control healthcare costs.
One of the goals of the PPACA is to make it easier for small businesses to ?.
offer insurance to their employees
What is the Small Business Health Options Program (SHOP)?
A marketplace created under the Affordable Care Act (ACA) that allows small businesses (typically those with 1 to 50 full-time employees) to offer affordable health and dental insurance to their employees.
What program is the below blurb referring to?
? allows the employer to control the coverage it is offering and how much it pays toward employee premiums. The employer can decide whether to offer dependent coverage and dental insurance, and it chooses the open enrollment period and waiting period for new employees. Employees can then enroll online, and the employer pays one bill. Employers with fewer than 25 employees may qualify for the Small Business Health Care Tax Credit of up to 50% of premium costs.
Small Business Health Options Program (SHOP)
The greatest benefits of Small Business Health Options Program (SHOP) are for employers with fewer than ? employees making under $25,000.
10
What is Medicaid?
A government insurance program for persons of all ages whose income and resources are insufficient to pay for health care. Medicaid is a federally initiated program, but it is primarily administered, and at least partially funded, at the state level. As such, each state sets its own criteria to qualify for benefits other than those federally mandated requirements.
? and ? provide health care coverage to children, pregnant women, parents, and disabled individuals with low incomes.
Medicaid; CHIP
There are generally two types of assets when calculating eligibility for Medicaid:
assets that are counted and those that are not.
Poverty alone does not qualify someone for Medicaid. In addition to income requirements, individuals need to satisfy federal and state requirements regarding:
residency, immigration status, and documentation of U.S. citizenship.
Because Medicaid, unlike Medicare, provides coverage for long-term care (LTC)—including nursing home care—many people are tempted to use this program as a way to shift the cost burden of nursing homes to the government. Due to this temptation, Medicaid law includes a provision defining a lookback period of ? months for assets transferred to others (usually adult children) designed to impoverish the donor to become eligible for Medicaid.
60
Recall that Medicaid is a joint ? and ? health insurance program.
federal; state
Generally, the program is administered by the states with financial assistance from the federal government.
What is the Children’s Health Insurance Program (CHIP)?
A federal program that is administered by the states. CHIP provides health insurance to children in families who do not qualify for Medicaid. Typically, CHIP benefits are applied for at the same time as Medicaid benefits.
What do the below situations represent?
Joshua’s health plan limits the number of chiropractic visits in a calendar year, specifies the number of days of inpatient care that will be provided for mental and nervous conditions, and requires that certain surgical procedures be performed on an outpatient basis.
Abby’s managed care plan will pay nothing if services are provided by a doctor who is not on an approved list of providers.
Justin’s health plan will provide a reduced benefit for treatment provided by nonapproved providers.
Unless prior approval is obtained, Oliver’s health plan will pay the cost of a procedure as if it was done as an outpatient treatment, even though it was performed in the hospital.
Internal limits of health insurance.
What is utilization review?
The process of evaluating the necessity, efficiency, and appropriateness of medical services, procedures, and treatments provided to patients. It is commonly used by health insurance companies, hospitals, and healthcare providers to ensure that care is medically necessary and cost-effective.
What is case management?
Another form of utilization review that is used to control costs and optimize patient benefits in the treatment of expensive illnesses such as diabetes, hypertension, AIDS, cancer, or heart disease.
What is a coordination of benefits provision?
Many working couples are covered as employees under their own employer’s plan, and each is also covered as a dependent under their spouse’s plan. This type of double coverage can result in individuals being overinsured—meaning that the individual is able to collect benefits in excess of the amount of the loss.
To avoid this situation, group health insurance policies contain a coordination of benefits provision that says if a loss is payable under two group health insurance plans, one plan will be considered primary and the other will be considered secondary. The primary plan pays benefits up to its limit first; the secondary insurance plan will pay up to its limit for costs not covered by the primary plan. The provision describes how to determine which plan is primary and which is secondary.
What is the maximum out-of-pocket (MOOP)?
The limit the insured will pay out of pocket for care. Most of the health plans today include the deductible, copayments, and coinsurance under the definition of MOOP.
One thing to keep in mind is that the MOOP limit only applies to ?.
approved charges
If the plan allows the insured to go out of network, but pays a lower percentage, the additional amount the insured is responsible for is not included in the MOOP calculation. Further, if the policy limits certain care (e.g., chiropractic) the additional care received is in addition to the MOOP.