EPIC Insurance Exam: Health Section

a person covered by a managed care plan (Kaiser/HMO) is a ...

"member", "participant", "subscriber"

Claims form provision

(required) insurer must provide claims form within 15 days of receiving the claim

Small Employer Medical Expese Plan

- 50 employees - must offer medical expense coverage to all eligible employee -preexisting conditions cannot be excluded for more than 1 year - employer must offer at least 2 medical plan options

What are the Essential Health Benefits

- anbulance - emergency servies - hospitalization - maternity and newborn care - mental health & substance abuse - prescription drugs - rehab - lab service - preventative and wellness services - chronic disease management - pediatric

Benefits Tied to Income (DI)

- no DI polic will be issued w benefits that are more than the insureds earnings - no DI benefits will be paid if the insured is not getting regular care from a physician - no DI benefits will be paid w/out periodic proof of loss (does not apply if the disability is total and permament)

Catastrophic Plan

-Must be under 30 years old. -Pays for 3 primary care physician visits before deductible applies. -High deductible and low premium -After deductible is met, costs are covered 100%.

Limited Benefit Plans

-accident -dread disease policy -critical illness -employer-sponsored plan -hospital indemnity -dental plans -short-term medical -vision/hearing plans

Social Security disability benefits

1. coverage requires a worker to be fully insured (if not permanently insured) 2. worker must be TOTALLY disabled (can do ANY work & disabled for a least 1 year) 3. 5 month waiting period from start of disability before OASDI begin 4. benefit = PIA (primary insurance amount)

Types of Health Insurance

1. disability income 2. medical expense 3. accidental death & dismemberment 4. medicare 5. LTC 7. limited benefit (voluntary)

What are the 12 required provisions in health insurance?

1. entire contract 2. time limit on certain defenses 3. grace period 4. reinstatement 5. physical exam and autopsy 6. legal actions 7. change of beni 8. payment of claims 9. notice of claim 10. claim form 11. proof of loss 12. time of payment

Two types of medical insurance

1. indemnity policies 2. managed care plans

Workers' Compensation Insurance

1. mandated by most states, employer-funded comp. that protects workers from injury or illness 2. benefits are paid regardless of who was at fault for worker's injury or illness 3. benefits include wage replacement, medical treatment, and vocational rehab

People who help you enroll in health insurance?

1. navigators 2. non-navigators assitant 3. exchange enrollment facilitators 4. certified application counselor and producers

Medicare

A FEDERAL program of health insurance for persons 65 years of age and older

Medicaid

A STATE assistance program that pays for health care services for people who cannot afford them. (any age/fed helps a little)

Indemnity Policy

A medical expense insurance policy that reimburses the insured for the cost of medical care. Associated with traditional medical insurance, indemnity policies let insured SELECT ANY doctor or medical care provider they prefer. These fee-for-service policies reimburse the insured for the cost of covered medical care received. Coverages are defined in the policy. - collects premiums from the insured and the insured pays for covered medical care, then reimburses the insured for some or all the cost of care

Probationary Period Provision

A specified period of time before coverage goes into effect . This is designed to protect the insurer for losses due to a sickness that immediately occur after the policy is issued. Losses due to an accident are covered immediately with no waiting period.

disability buy-out policy

A type of DI policy that provides surviving business owners with the funds needed to execute a buy-sell agreement upon a co-owner's disability. Disability buy-out policies typically pay benefits in a lump sum that is then used to buy the disabled owner's business interest. These policies typically have a long elimination period (i.e., 18 to 24 months or more).

Medical Expense Insurance

A type of insurance that pays benefits for medical, surgical, and hospital costs.

What is the ACA?

Affordable Care Act - policy is sold on guaranteed issue basis - med coverage is available regardless of pre-existing coniditons - dependent children are coverd - low-income can take advantage of Fed subsidies and medicaid - coverage must meet a minimum standard - states set up health insurance exchanges for small biz and individual **** only applies to medial expense insurance

Grandfathered Health Plan

An individual health insurance policy purchased on or before March 23, 2010. These plans were not sold through the Marketplace, but by insurance companies, agents, or brokers. They may not include some rights and protections provided under the Affordable Care Act (preventative services, can do annual limits, exclude preexisting)

Medical Information Bureau (MIB)

An information database that stores the health histories of individuals who have applied for insurance in the past. Most insurance companies subscribe to this database for underwriting purposes.

Nondisabling Injury

An injury which may require medical care, but does not result in loss of working time or income.

Conditional Receipt

An interim insuring agreement under which the insurance company agrees to start coverage on the later of either the date of application or the date of the medical exam IF the proposed insured is found to be insurable on that date.

Benefits schedule vs Usual, Customary, & Reasonable charges

Benefit: insurer assigns a "price" to each medical cost, and pays a % or the full amount UCR: more common - amount payable is based on what is usual, common, reasonable for the area that service is performed both have a stated max amount

Metal Levels of health insurance

Bronze: plan(60%) you(40%) Silver: plan(70%) you(30%) Gold: plan(80%) you(20%) Platinum: plan(90%) you(10%)

Supplemental Major Medical Policy

Covers costs beyond what a basic medical expense plan pays for. - have a high deductible bc of the first dollar coverage - the high deductible avoids duplicate coverage and helps keep premiums low

Unpaid Premium Provision

Deducts an unpaid premium from the claim payment.

Field Underwriting

During this process, the producer determines which risks are desirable and submits those to the underwriting department for approval. The producer provides any required disclosure of information practices to an applicant, such as a notice regarding replacement, a buyer's guide, an outline of coverage, or a policy summary.

Future Increase Option (FIO) Rider

Enables the insured to purchase additional coverage, regardless of insurability, at specified future option dates - usually must buy it within a certain period and before a certain age

Business Overhead Expense Insurance

If a business owner becomes disabled, this policy will not replace the owner's income, but will instead help pay the expenses of operating the business such as : rent, utilities, taxes, and wages - short elimination period makes benefits available in 1st month

Other Insurance in this insurer provision

Limits total coverage from a single insurer when insured has two or more related policies with the same insurer.

is a recurrent disability subject to a new elimination period or new maximum benefit period?

NO

Are their lifetime limits on health plans?

NO the ACA protects that for all health plans

Waiver of Premium Rider

Optional rider that requires an insurer to assume payment of premiums should the insured become totally disabled

FICA taxes

Payroll taxes withheld to provide Social Security and Medicare benefits

Proof of Loss provision

Policy owner has 90 days from date of loss to submit proof of loss to Insurer; valid claim must be paid immediately upon receipt.

probationary period vs elimination period

Porbationary: amount of time you have to wait to FILE A CLAIM - only occurs ONCE Elimination: amount of time you have to wait until you RECEIVE benefits - occurs with every disability

Medicare Supplement

Private insurance plan available to Medicare-eligible persons to cover the costs of medical care not covered by Medicare.

Own-occupation policy

Provides benefits if you can no longer perform the occupation you had at the time you became disabled - but the insured can work other ways but not in that occupation - typically costs more bc it is easier to qualify

long-term care insurance

Provides payment for extended nursing care due to accidents, illness, or old age

Relation of Earnings to Insurance provision

Reduces the disability income policy's income benefit amount if it exceeds the insured's wages.

Disability Income

Replaces lost income in the event of disability

managed care plans

SYSTEMS of health care delivery that combine characteristics of health care and an insurer - collect premiums from the insured, then pays for covered medical care, insured may contribute a copayment

Who has primary authority to regulate health insurance?

States But.... federal govt regulates PPACA aka ACA (affordable care act)

The disability must last through the elimination period before the insured can receive benefits. T or F

TRUE

recurrent disability arises when the policy is in force and WITHIN 6 months of previous related disability. T or F

TRUE

the relation-to-earnings provision (participation limit) prevents the total disability benefits from ALL policies the insured owns from exceeding the insured's pre-disability earnings. T or F

TRUE

Medical Loss Ratio (MLR)

The percentage of premium dollars an insurance company spends on medical care, as opposed to administrative costs or profits. Under the ACA, beginning in 2011, large group plans are required to spend at least 85 percent of premium dollars on health care and quality improvement, while individual plans must spend at least 80 percent.

other insurance with other insurers provision

When more than one insurer covers a loss, allocates each insurer's share of the total benefit due.

managed care plans such as HMO and PPO operate on....

a prepaid basis

If you want to pay the least premium for a disabilty income policy you should chose one with...

a short benefit period

Comprehensive Major Medical Insurance

a type of major medical insurance that has a very low deductible and are independent plans

Residual Disability Benefit usually end when

an insuerd's income loss is less than 20% of pre-disability earnings

A person covered by a traditional indemnity policy is called....

an insured

Conformity with State Statutes Provision

any non-compliant provisions automatically conform to the min. state requirement

Claims: Reimbursement contract

base the amount of benefit on the loss - medical expense policies are reimbursement contracts

income disability pays how mcuh?

benefit amount is equal to the amount of income lost

How do add dependents on health insurance policy?

birth, adoption, marriage

Insurance With Other Insurers Provision

calls for the prorating of benefits that are payable on any basis other than expenses incurred

What are the 11 Optional Provisions?

can be added - they protect the insurer

Disability Reducing Term Insurance

covers outstanding business loans when the business owner becomes disabled

Primary Purpose of Federal Tax-Favoured health plans?

encourage people and employers to save for health care expenses

Binding Receipt

guarentees coverage from the time of the applicant completes the app - gives coverage during the underwriting period

First dollar coverage plans

how basic medical expense plans pay claims - the insured does not pay a deductible or copay - these policies pay all covered expenses up to the policy's max amount types: 1. hospital 2. surgical 3. physician

Major Medical Insurance

insurance that includes treatment for long-term, high-cost illnesses or injuries and inpatient and outpatient expenses. usually only exclude: cosmetic surgery, occupational illness or injury, and routine vision & dental care

Preventative Care Services

insured does NOT pay copayment or coinsurance even if annual deductible has not been met - blood pressure - depression screening - diabetes (type 2) - vaccines - TB screening

how to set UCR rates?

insurer refers to a database that rank med procedures according to cost for the geographical area

Recurrent Disability Provision

is when an insured was disabled then recovered then got disabled again - is from the same or related cause of an earlier disabillity for which the elimination period was satisfied - begins within 6 months from the end of the earlier, related disability

what is the cancellation provision?

lets the insurer cancel the policy at any time with 45 day notice

Government Insurance Programs

medicare, medicaid, social security, state workers comp.

Does HIPAA apply to the solicitation (buying/selling proccess) of health insurace?

no

most DI policies only cover....

nonoccupational disabilities (not at work) - but may cover a self-employed occupational injury

The Notice of Claims provision requires the insured to

notify the insurer within 20 days after a loss

Can a person enroll after open enrollment?

only if there is a qualifying life event: - marriage - birth - loss of other health insurance (quitting your plan does NOT count) - moving - becoming a US citizen - release from prison

Who is permitted to change the information in a health insurance application?

only the applicant

who can change the policy?

only the exec officer of the company

Claims: valued contracts

pay with a stipulated sum, no regard for actual expenses - accidental death & dismemberment & ife insurance are valued contracts - dread disease: a policy that pays a stated value upon loss (also a valued contract)

Reinstatement Provision

permits the owner to reinstate a lapsed policy - accidents are immediately covered but some coverage on things like sickness can delay (protects against adverse selection)

elmination period is like what?

policy deductible - time before DI benefits become payable

Plans issued after Jan 1 2014 MUST cover....

pre-existing conditions for adults and dependents plans before march 23 2010 have grandfather status and do not have to comply

Individual Disability Income

premiums not tax-deductible & benefits not taxable

Grace Period Provision

prevents policies from lapsing if a policyowner forgets or neglects to pay their premium it gives them a grace period (length depends on how often the premium is paid)

the application for health insurance requires who to sign?

proposed insured and producer

Guarenteed Insurability Rider (GIR)

protects the insureds right to buy more coverage in the future without the need to prove good health

any-occupation policy

provides full benefits only if the insured cannot perform any occupation - it favors the insurer bc the chance of paying a loss is lower

Return of Premium Rider

refunds some of the premiums paid for the policy if the insured made no claims during a certain period, or if the claims were less than a certain amount

any premium paid for coverage that is more than needed is...

returned to the inusred

Time Limit on Certain Defenses

states that after the policy has been in force for two years, the insurer cannot void the policy or deny a claim on the basis of misstatements in the application, except for fraudulent misstatements

Under group disability income, if an employee suffers a disabling injury, the benefits paid to the employee are ......

taxable income to the employee

when social security disability begins,

the SIS (social insurance supplement) will diminish or end

what happens in a cancelable policy?

the insurer must refund any advance premiums (they don't need to give an explanation)

Key Person Disability Income insurance does NOT pay for...

the key person's lost wages

the longer the elimination period...

the lower the premium for comparable disability benefits

Health insurance marketplace (health insurance exchange)

the public can compare plans, shop around, buy from private insurance healthcare.gov

a worker who accepts workers' comp. forfeits....

the right to sue employer for compensation

benefit period in credit disability insurance policy is

the same as the loan period

Who determines the premium rate?

underwriter

Corridor Deductible

used only with supplemental major medical policies - is applied AFTER basic plan but BEFORE supplementary benefits kick in

For group DI policy, the insurer underwrites the group as a

whole