Other Health Insurance Concepts Flashcards
An owner of an individual health insurance policy with a death benefit wants to change the beneficiary, what is the only time in which the owner of the policy cannot change the beneficiary?
If the beneficiary is deemed irrevocable.
How long must insurers cover dependent children according to the Affordable Care Act?
Up to the age of 26. Regardless of their marital status, residency, financial dependence on their parents or eligibility to enroll in their employer’s plan.
What is an exception to the 26 year old age limit?
If the dependent is incapable of self-support because of physical or mental handicap. Proof of dependency is required annually after a 2-year period following attainment of the maximum age.
What provision states that an individual health insurance policy provides a death benefit, it must also include a change of beneficiary?
Change of beneficiary provision unless the beneficiary is irrevocable
What does modes of premium payment refer to?
The frequency that premiums are paid
Why is a higher mode of payment correlated to a higher premium?
Because the company willl have additional expenses in billing the premium store frequently.
What is the purpose of the coordination of benefits (COB) provision?
The purpose is to avoid duplication of benefit payments and overinsurance when an individual is covered under multiple group health insurance plans.
Is the coordination of benefits (COB) provision found in individual policies or group policies?
Group policies only
What provision prevents total amount of claims paid from all insurers covering the patient from being more than the total allowable medical expenses?
Coordination of Benefits (COB) provision
How does the Coordination of Benefits (COB) provision prevent over insurance?
Ranks multiple group insurance through primary, secondary, tertiary.
If a couple is married and they both have group insurances through their work which is the primary?
Their personal grou-p work insurance is the primary and their partners insurance is the secondary.
If a married couple has a child and both of their work covers their child who is deemed the primary coverage?
Which ever parent’s birthday is first.
What is occupational coverage?
Occupational coverage provides benefits for illness, injury or disability resulting from accidents or sicknesses that occur on or off the job.
What is nonoccupational coverage?
Only covers claims that result from accidents or sicknesses occurring off the job.
What is the definition of partial disability?
Defined as the inability to perform one or more of the regular duties of one’s OWN OCCUPATION or the inability to work on a full-time basis, which results in a decrease in the individual’s income.
What is the purpose of partial disability?
To cover a partial loss of income when the insured is disabled to the point of being able to report to work, but not being able to perform all of the regular duties of the job.
How much does partial disability cover?
50% of the total disability benefit and limited to a certain time period.
What is the definition of recurrent disability?
A policy provision that specifies the period of time (usually within 3-6 months), during which the recurrence of an injury or illness will b e considered as a continuation of a prior period of disability
What does recurrent disability provision protect the insured from?
Another elimination period
What is residual disability?
The type of disability income policy that provides benefits for loss of income when a person returns to work after a total disability, but is still not able to work as long or at the same level he/she worked before becoming disabled.
How does residual disability work?
If the person can only work part-time or at a lesser paying position, residual disability will make up the difference between their present earnings and what they were earning prior to disability.
What does the cost-saving services or case-management provisions do?
Provide plans 3iwth controlled access to healthcare through the use of case managers.
Used to large, ongoing claims.
What is preauthorization?
A cost-containment measure requiring that the insured obtain approval from the insurer before getting an expensive surgery, referred to a specialist, or nonemergency healthcare service.
