Types of Accident and Sickness Policies Flashcards
types of employee benefit plan that allows insureds to choose between different types of benefits
cafeteria plan
health insurance that provides coverage for most types of medical expenses
comprehensive coverage
a specified dollar amount that the insured must pay before the insurance company will pay the policy benefits
deductible
risk selection and classification process
underwriting
basic hospital, surgical, and medical policies and major medical policies are grouped as
medical expense insurance
accident and sickness insurance that usually does not require a deductable
first dollar coverage
lists the type of operations covered and their assigned dollar amount
surgical schedule
each surgical procedure will be assigned a number of points that are relative to the number of points assigned to the maximum beneit
relative value
used to supplement the coverage payable under a basic medical expense policy
Supplementary Major Medical Policies
applied between the basic coverage and the major medical coverage
corridor deductible
How was the growth of HMO’s supported in this country?
Health Mainetenance Act of 1973
used for the benefit of preventive care
HMO’s
provides benefits in the form of services rather than reimbursement
HMO
When becoming a member of HMO, you choose a
primary care physician or gate keeper
physicians are paid fees or their services, rather than a salary, but the member is encouraged to visit approved member physicians that have previously agreed upon the fees to be charged
Preferred Provider Organization
group of physicians and hospitals that contract with employers, insurers, or third party organizations to provide medical care services at a reduced fee
PPO
2 ways PPOs differ from HMOs
PPOs do not provide care on a prepaid basis, and subscribers arent required to use physicians or facilities that have contracts with PPOs
combination of HMO and PPO plans
Point of Service
a form of cafeteria plan benefit funded by salary reduction and employer contributions
Flexible Spending Account
for out of pocket health care expenses
health care account
help pay for dependents care expenses which makes it possible for an employee and his or her spouse to continue to work
dependent care account
features higher annual deductables and out of pocke limits than traditional health plans, which means lower premiums
High deductable health plans
designed to help individuals save or qualified health expenses that they, their spouse, or their dependents incur
Health Savings Accounts
designed to replace lost income in the event of not being able to go to work, and is a vital component of a comprehensive insurance program
disability income insurance
a waiting period that is imposed on the insured from the onset of disability until benefit payments commence
Elimination period
purpose is to eliminate coverage for short term disabilities in which the insured will be able to return to work in a relatively short period
elimination period
another type of waiting period that is imposed under some disability income policies
probationary period
refers to the length of time over which the monthly disability benefit payments will last for each disability after the elimination period has been satisfied
benefit period
a provision that is found in most disability income policies which specifies the conditions that will automatically qualify the insured for full disability benefits
presumptive disability
the amount of monthly beneit that is payable under most disability income policies is based on a percentage of the insureds past earnings
benefit limitations
used to supplement or replace beneits that mght be payable undere the social security disability
social insurance supplement or social security riders
a unique type of policy that is sold to small business owners who must continue to meet overhead expenses such as rent, utilities, employee salaries, installment purchases, leased equiptment, etc, following a disability
business overhead expense
specifies who will purchase a disabled partners interest and legally obligates that person or party to purchase such interest upon disability
disability buyout agreement
contract is owned by the business, paid by the business, and business gets benefits but the one employee is the insured
key person disability
paid for accidental death
principle sum
percentage of the principle sum
capital sum
defines the specific risk in which accidental death or dismemberment benefits will be paid
limited risk policy
will cover unusual types of risks that are not normally covered under AD&D policies
Special Risk policy
provide coverage for individuals who are no longer able to live an independent lifestyle and require living assistance at home or in a nursing home facility
long term care policies
long term care policies can be marketed as
individual, group, or riders
what three levels of care does the long term care policies cover?
skilled care, intermediate care, and custodial care
daily nursing and rehabilitative care that can only be provided by medical personnel, under the direction of a physician
skilled care
occasional nursing or rehabilitative care provided for stable conditions that require daily medical assistance on a less frequent basis than skilled nursing
intermediate care
care for meeting personal needs such as assistance in eating, dressing, or bating which can be provided by nonmedical personnel
Custodial Care
care provided by a skilled nursing or other professional service in ones home
home health care
provided in the insureds home under a planned program established by his or her attending physician
home convalescent care
provided while the insured resides in a retirement community or residential care facility for the elderly
residential care
care provided for functionally impaired adults on less than a 24 hour basis
Adult day care
designed to provide relief to the family caregiver and can include a service such as someone coming to the home while the caregiver takes a nap or goes out for a little while
respite care
most common LTC contract in the private market
Individual long term contract
the employer provides group coverage to its employees
employer sponsored group
can buy group insurance for its members (done by alumni or professional)
association group
requires any employer with 20 or more employees to extend group health coverage to terminated employees and their families after qualifying event
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
cobra events call for how many months to be extended?
18
cobra events such as death or divorce are extended how long?
36
COBRA benefits are applied to what kind of insurance
group health
insurance plans are designed to provide temporary coverage for people in transition and are unavailable for terms from one month up to 11
short term medical
limited policies that only provide coverage for death, dismemberment, disability, or hospital care due to an accident
accident only
covers multiple illnesses and pays a lump sum benefit to the insured upon the diagnosis of any disease or illness
critical illness
provides a specific amount on a time basis while the insured is confined to a hospital
hospital indemnity
a form of medical expense health insurance that covers the treatment, care, and prevention of dental disease and injury to the insureds teeth
dental expense
the employer provides group coverage to its employees
employer-sponsored group
social security supplement or social security riders would provide for the payment of income benefits in each of the situations EXCEPT
when the amount payable under social security is more than the amount payable under the rider
the type of dental plan which is incorporated into a major medical expense plan is an
integrated dental plan
what would be an example of a limited accident and health insurance policy
dread disease policy
Using the point system to find out how much money you get for surgeries is what
relative value
in a disability policy, the probationary period refers to the time
during which illness related disabilities are excluded from coverage
what special policy covers unusual risks that are not normally included under accidental death and dismemberment coverage?
special risk policy
an insured who has an accidental death and dismemberment policy loses her left arm in an accident . what type of benefit will she most likely receive from this policy?
the capital amount in a lump sum
most policies pay the accident death benefits as long as the death is caused by the accident and occurs within
90 days
long term care coverage may be available as everything except
endorsement to a health policy
the gatekeeper of an HMO helps
control specialist costs
