Unit 33: Special Types of Health Policies Flashcards
Most dental policies are what?
comprehensive policies that work much the same way as comprehensive medical expense coverage
Some dental policies are scheduled, which means what in regards to benefits? Pg 474
They are limited to specified maximums per procedure, with first dollar coverage.
Comprehensive dental plans usually provide what in regard to coverage? how do deductibles come into play?
they provide routine dental care services without deductibles or coinsurance to encourage preventitive dental care
Textbook: Generally there is a specified maximum dollar amount payable per year, and sometimes, per family member covered
Subject: Dental Care Question: for non routine treatments, a comprehensive policy pays what (regarding the charges)? what does the patient pay?
the comprehensive policy pays a percentage of the reasonable and customary charges. the patient pays an annual deductible and whatever expense remains
What is the vertical dimension, splinting, and restoring occlusion exclusion?
limits liability for exotic and highly optional procedures
How does an insurer often reduce its liability for payment of dental expenses by contractual provisions?
they state what a plan does cover and what it will not cover
What is the 5 year replacement exclusion?
this exclusion pertains to not allowing replacement of prosthetic appliances (such as retainers or spacers) for 5 years after benefit is paid
what are exclusions and limitations from the dental care coverage? 5 things
- Cosmetic exclusion
- missing tooth provision
- 5 year replacement exclusion
- vertical dimension, splinting, and restoring occlusion exclusion
- expenses for oral hygiene instructions and plaque control programs are often limited or excluded
what is the cosmetic exclusion?
this exclusion says that benefits are not payable for dental work that is not necessary to have good teeth. extravigant stuff is not needed. anything out of what is required to have good teeth is not covered
what is the missing tooth provision (remember provisions protect the company as well so it would be something they do not want to cover)?
excludes coverage for teeth that are missing when the coverage becomes effective
What is hospital income or hospital indemnity coverage? (think literally terms)
a policy that pays a specific amount of insurance for each day an individual is hospitalized
What are dread policies and what do they do?
they are policies that protect you if a dread diseases occurs but they are policies you can buy to cover specific diseases that are named in the policy such as heart disease or cancer
What are dread diseases? What is the cost related to them?
diseases that are “dreadful” and do not occur frequently. They are very expensive to
What is the rule on oral hygiene instructions and plaque control when it comes to what is covered or not?
these programs are often limited and excluded
who gets paid in the hospital income or hospital indemnity coverage?
the insured not the hospital
What is the intention of hospital income or hospital indemnity policies?
They are note dsigned to cover expenses for being in the hospital but rather are designed to give an insured a flow of income that begins when the insured is confined to the hospital and ends on the final day of hospitalization
What do some people do with the hospital income or hospital indemnity that comes from the policy that as the same name
some insureds may use that money to meet deductibles and coinsurance requirements of their medical expense policy
Although basic, comprehensive, and major medical policies often cover disease and injury to the eyes, there is generally no what?
coverage for eye exams and corrections such as eye glasses or contact lenses
how do insurers clsoe the gap where coverage for eye exams and corrections such as eye glasses or contact lenses are not covered?
they may over vision care policies
What is the purpose of long term care (LTC policies)
There was an increase in the number of benefits of long-term care insurance policies, they designed to cover many of the expenses associated with residence in and out of hospital facilities
With the federal government responding to consumer interests in long term care (LTC) coverages, the National association of Insurance commissioners (NAIC) developed a model to help state legislatures in an effort to keep regulation on a sate level. More than half ot the states currently use the NAIC model. What are the two key issues it covers?
- a benefit period of at least one year
- strict restrictions on cancellation, specifically prohibiting cancellation because of the insured’s aging - most policies now guarantee renewability
How are LTC polices different than other health plans?
they are rated differently snd they use a different means of classification determine whether or not somebody is a standard risk
What is the determining factor for LTC policies if they are going to ensure someone?
The key is whether or not an individual can perform activities of daily living with a degree of proficiency
What are the activities of daily living (ADL’s)?
Dressing, bathing, eating, walking, and similar activities
IS an individual with heart disease who is still able to perform ADLs insurable?
yes they are. they are a standard risk whereas for other policies they would be a substandard risk
What are the 3 terms that are important to know when it comes to LTC policies to know what they cover?
- Skilled nursing care (skilled medical people, doctor’s orders, daily)
- Intermediate care (skilled medical people, doctor’s orders, occasionally)
- Custodial or residential care (help in performing ADLS by someone without skills or training, need doctor’s orders)
They’re all one based on the doctors orders, two vary in timing, and first two can be skilled whereas last one doesn’t need to be
What is skilled nursing care, that is covered by LTC policies and how often is it covered?
nursing and rehab care can only be performed by skilled medical practitioners on the doctors order. DAILY
What is intermediate care, that is covered by LTC policies and how often is it covered?
Nursing and rehab care that is required and can only be performed by skilled medical practitioners on the doctors orders. OCCASIONALLY
What is custodial, residential care, that is covered by LTC policies and how often is it covered?
Helping performing activities of daily living by someone without medical skills or training, but it has to be based on the doctors order
What does home health care in regards to LTC policies?
Services performed from TIME TO TIME in individuals home. It may include skilled nursing, various types of therapy, help with ADLs, come and help with housework. MUST OFFER IN KY
What does Adult day care in regards to LTC policies?
Adult daycare provides company, supervision, social, and recreational support during the day for people who live at home and need assistance. The service is especially useful, for those are being cared for by relatives who work during the day.
The difference between this and home health care is that this is more frequent
What is the youngest and oldest ages at which LTC policies may be purchased provision?
The age in which these policies may be purchased is different because now, instead of the minimum age being between 50 and 60 years old, you know I’m a purchase one as low as 18 years old. And now you may buy one anywhere in the age range of 69 years old to 89 years old.
What are the 6 provisions connected with LTC policies
- Youngest and oldest ages at which LTC policies may be purchased
- Waiver of premium
- Prior Hospitalization
- Home Health Care
- Adult Day Care
- Inflation protection
What is the waiver of premium provision in LTC policies? When does care start again?
Almost all LTC policies include the waiver of premium provision after the insured has been confined and in care for a certain number of days. In most cases, the certain number of days is 90 but it can be as long as 180 days and some policies.
Premium payment start back up once Carol is done
What is the prior hospitalization provision and LTC policies?
Most nursing home policies required a person to be in the hospital prior to confinement to a nursing home in order for the benefits to be paid, but that no longer is the case
What is the home healthcare provisioning LTC policies?
Most LTC policies now cover home health care as an alternative to nursing home care
What is the adult, daycare provision in LTC policies? protects the worker
This allows a primary caregiver who works opportunity to tend to his appointment responsibilities.
What is the inflation provision? How do you get this provision? (think premium)MUST OFFER IN KY
For an additional premium amount, LTC policies, offer, automatic percentage increases and benefits every year, or as an alternative, periodic opportunities to purchase a higher level of benefits, without evidence of insurability
How do large insurance companies market LTC coverage?
They use a third marketing device which involves attaching an LTC rider to a life insurance policy, called “accelerated benefits, writer” or “living benefit rider”
What is credit insurance? What is the purpose of credit insurance? pg 483 + 484
It is insurance that covers the company who has an insurance who owes them money
Text: Credit health insurance covers a debtor with a creditor, receiving the benefits to pay off the debt if the debtor is disabled or dies accidentally. What does means is that when the person I was the death dies the person who ultimately want to pay them at the end of the day is taken care of.
The purpose of credit insurance is there, and share that the outstanding indebtedness will be paid if the insured is disabled, or does accidentally before the loan is repaid. The accidental death benefit may not exceed the total amount of indebtedness at any given point, nor may the monthly disability benefit exceed them out of the monthly payment on the loan.
What is the minimum number of debtors a creditor must have per year before it qualifies for Group credit insurance?
100
Does credit health insurance cover a debtor if he dies a natural death? What would cover them?
no, credit life insurance
What is credit life insurance?
This will pay death benefits, whether or not death occurs by accident or naturally. This is not considered health insurance because it provides for natural death, benefits, whereas health insurance covers only accidental death
Who is the beneficiary in credit life insurance?
Whether individual or group coverage, the creditor is the beneficiary of the policy
