Types of Policies [Health] Flashcards
Entire Contract
the policy, provisions, copy of the application, riders, and waivers; changes made to the policy must be requested in writing and signed by the insurer
Time Limit on Certain Defenses
Misstatements on an application cannot be used to deny a claim after the policy has been in force for 2 years
Grace Period
period of time after the premium due date, that the policy owner has to pay the premium before the policy lapses.; 7 days - weekly premium, 10 days - monthly premium, 31 days - all other premium modes (quarterly, bi-annually, annually)
Reinstatement
A policy can be restored within a specified period of time with proof of insurability; if the insurer does not reject the late payment within 45 days, the policy automatically goes back into effect
Individual disability income policy
pays an income benefit when the insured is unable to work due to a covered illness or injury; typically paid monthly and is 60-70% of the insureds current net earnings
Business overhead expense policy
provides funds to cover the overhead expenses of a business when the owner becomes disabled; office rent, utilities, employee labor, not the owner’s income loss
Group disability income policy
weekly or monthly cash payments to employees disabled from accidents or illness/ benefits percentage of worker’s income, policy flat amount/ employee worked for 30 to 90 days/ some plans limit to non-occupational disabilities
Key employee policy
if a key employee becomes disabled,this policy pays a benefit by helping pay for a replacement, train a new employee, or replace loss of revenue
Basic hospital
Coverage that provides benefits for room, board and miscellaneous hospital expenses for a certain number of days during a hospital stay.
Major medical policies
provides benefits for catastrophic and prolonged injury or illness. High max. limit. Deductible-amount insured must meet per year before benefits are paid. Family Deductible; Carryover Provision; Common Accident
Health Maintenance Organizations (HMOs)
managed care plan; services on a prepaid basis with little out of pocket cost; Members are SUBSCRIBERS within a specific geographic region called SERVICE AREA; service providers are paid a capitation fee per enrollee; Coverage not provided outside area except for emergencies. Emphasize preventive care; PCP is gatekeeper
Preferred Provider Organizations (PPOs)
managed Care plans arranged through a network of providers; providers perform services to subscribers and charge a discounted fee negotiated in advance; subscribers can use in or out of network provider; no gatekeeper
Point of Service (POS) plan
managed care plan; Combines HMO and PPO benefits; subscriber can choose which plan to use; within network, benefits paid as an HMO with a PCP or gatekeeper; out of network services will have higher out of pocket costs like PPO, with no PCP
Flexible Spending Accounts (FSAs)
can only be offered through employment; employer contributions are made on a pretax basis; withdraws pay for qualified medical and dental expenses; USE IT OR LOSE IT
High Deductible Health Plans (HDHPs) and related Health Savings Accounts (HSAs)
premiums are significantly low; Higher deductible and higher out of pocket limits
Medicare supplement policies
called Medigap; fill in the coverage gaps of Original Medicare; plans A - N; plan A is the core benefits; plans B - N must include benefits of plan A
Individual Contracts
insured receives a policy, provides evidence of insurability, can be purchased at any time, lower limits and higher deductibles
Group Contracts
the employer receives the master policy, employees receive a certificate of insurance a summary of benefits; no evidence of insurability needed; underwriting is based on experience and community ratings; purchased after a probationary period during the open enrollment, higher limits, and lower out of pocket costs; more comprehensive
Hospital indemnity
pays a specified dollar amount per day to the insured during hospitalization
Short-term medical
temporary coverage that provides limited benefits for 30 days to 12 months. Designed as “interim plans” to immediately fill gaps due to lost coverage
Accident
provides benefits for accidental injuries associated with specific events, such as foreign travel, cruise, airplane, etc.; provides blanket coverage for large groups
Disability Income Insurance
This is designed to replace lost income in the event of a disability
Probationary Period
This is another type of waiting period that is imposed under some disability income policies that adds onto the elimination period
How many days after the accident must the death occur within for the accidental death benefit to be payed?
90 days
Limited Risk Policy
This policy defines the specific risk in which accidental death or dismemberment benefits will be payed
Special Risk Policy
This policy will cover unusual types of risks that are not normally covered under AD&D policies
Skilled Care
This is daily nursing and rehabilitative care that can only be provided by medical personnel, under direction of physician. This is ONLY care that can be given by professional staff
Respite Care
This is 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 awhile
To convert group health to individual insurance, how soon must it be initiated after termination?
31 days
Under COBRA, how long must coverage normally be extended?
up to 18 months
Under COBRA, for events such as death or divorce, how long must coverage be extended for dependents?
36 months
Basic medical
coverage for nonsurgical services a physician provides/ limits on visits, cost, hospital stays/ Covers emergency accidents, maternity benefits, mental and nervous disorders, hospice care, nurses expenses
Basic Surgical
Covers costs of surgeons’ services, whether the surgery is performed in or out of the hospital/ No deductible but cost limited/ may assign relative value/ Written in conjunction w/ hospital exp. policies.
