Health insurance plans
life settlement broker found guilty of fraudulent acts may face what penalty(s)
- 10,000 for each violation - revocation of license for at least 1 year
HMO vs PPO
- HMO (health maintenance organization) is more restrictive than PPO (preferred provider organization. PPOs allow more flexibility between in-network and out-of-network providers, in exchange for higher premium. - PPOs offer larger selection of providers than HMOs
HMO copayments and deductible
- HMO includes copayment, paid by members - usually no deductible required in HMO plans
an exchange can help the applicant do the following
- compare private health plans - obtain info about health coverage options to make educated decisions - obtain information about eligibility for tax credits for most affordable coverage - enroll In health plans that meet applicants needs
group plan requirements under ACA
- discrimination in favor of highly compensated employees is prohibited - insurance covg in group Market must be guaranteed to all employees - the plan must comply with cost sharing limits set for group health coverage - waiting period cant be longer than 90 days
when insurers set premium rates, they are based on what 4 standards
- geographic rating area (location of residence in state) - family composition (single or family enrollment) - age - Tobacco use
HMO preventative care services
- main goal to reduce cost through prevent care - free annual check ups for family - free or low cost immunizations
PPACA Eligibility
- must be us citizen or be lawfully present in us - must live in the us - cant be in jail
group health coverage may be discontinued or non renewed because of
- nonpayment of premium - fraud - violation of participation or contribution rules - discontinuation of that particular coverage - movement outside the service area - leaving the association
Patient Protection and Affordable Care Act designed to
- set up a new competitive private health insurance market - hold companies accountable by keeping premiums low, preventing denials of care - help stabilize budget and economy through reducing the deficit by cutting govt spending - extend coverage for adult children to age 26
punishment for misrepresentation
1,000 or up to 6 months in jail
Major Medical Expense exclusions from coverage
1. injuries caused by war 2. intentional self inflicting injuries 3. regular dental/vision/hearing care 4. custodial care 5. injuries caused by workers comp insurance 6. cosmetic surgery (unless Medically necessary)
specified coverage can be written as
1. stand alone individual policy 2. to complement a traditional fee-for-service Medical Expense Policy
all reinsurance intermediary license must maintain records of reinsurance transactions for at least how many years
10 years
any person who violates cease and desist order, faces penalty of
10,000 for each violation
any individual insurance producer who allows their license to lapse may, within ------ from due date of renewal fee, reinstate the same license without passing a written exam
12 months
portable electronic license valid for
2 year period
Complaint records must be kept for how long by the insurance company?
2 years and myst be available for examination by commissioner
upon payment of renewal fees, the commissioner may renew insurance advisors licenses for any succeeding ----- period without requiring the detailed information that was required for insurance of the initial insurance advisors license
3 year period
applicants for reinsurance intermediary license must have held a producers license for at least --- in the lines applied for.
3 years
a producer must report to the commissioner any administrative action taken against such producer in another jurisdiction or by another governmental agency in the state within ------ of the final disposition of the matter
30 days
Licensees must inform commissioner of change of address within how many days
30 days of change of address
during every 36 month licensing period, licensees must complete how many hours after initial period
45 hours (including 3 in ethics)
the commissioner may examine any company at any time, but at least once every ---
5 years
during every 36 month licensing period, licensees must complete how many hours during the licensees first licensing period
60 hours (3 in ethics)
ACA has prohibited pre existing conditions exclusion and eliminated waiting periods in excess of --- days
90 days
HIPAA protection for coverage under individual health plans:
> guaranteed access to individual policies for qualified individuals > guaranteed renewability of individual policies
Under HIPAA, what are the requirements to convert from a group plan to an individual plan
> have 18 months of continuous credible health covg > covered under group plan in most recent insurance > have not used up any COBRA or state contin covg > not eligible for Medicare or Medicaid > not have any other health insurance > apply for individual health insur within 63 days of losing prior coverage
HIPAA protection for coverage under group health plans:
> prohibits discrimination against employees and dependents based on health condition > allows opportunities to enroll in a new plan to individuals in special circumstances
preventative benefits ACA
ACA requires 100% of preventative care covered without cost sharing.
BC/BS Basic Medical, Major medical and HMO plans
BC/BS offers indemnity plans, PPO plans, HMO plans and medicare extension programs
Early Intervention Services
Federally mandated evaluation and therapy services for children in the age range from birth to 3 years under the Individuals with Disabilities Education Act.
HMO Hospital care
HMO provides member with hospital care in or out of service area. services may be limited for mental, emotional, or nervous disorders including alcohol or drug rehab or treatment.
Lifetime and Annual Limits
Health plans are restricted from applying a dollar limit on essential benefits, nor can they establish a dollar limit on the amount of benefits paid during the course of an insured's lifetime.
enrollment period dates
November 1st to January 31st
PPOs General characteristics
PPO is group of physicians and hospitals that contract with employers, insurance companies, and 3rd party organizations to provide medical care at reduced fee
PPO indemnity plan features
PPOs channel patients to providers that are discounting their services, thereby lowering claim costs. copayments pay be charged per visit or hospital stay.
retrospective review
The part of the utilization review process that concentrates on a review of clinical information following patient discharge. can include hospital bill audits
Prospective Review
The physician can submit claim information prior to providing treatment to know in advance if the procedure is covered under the insured's plan and at what rate it will be paid.
what I the punishment against any person who refuses to submit to an examination as requested by the commissioner
a fine of 1,000 or maximum term of 1 year in jail
Life Settlement Broker
a person who, for compensation, solicits, negotiates, or offers to negotiate a life settlement contract. life settlement contracts are between a policy owner of a life insurance company and a life settlement provider.
disclosure benefits
accident and health insurance policy must have the appropriate disclosure form issued to policyholder. The disclosure generally lists major benefits and exclusions of policy.
the outline of coverage
advises recipient to read the outline carefully, pointing out the policy is not identical to the coverage requested.
Disabled adult children
all accident and sickness policies that provide coverage for dependent children, must insure mentally or physically disabled children of insured w/out limitations of age. proof of incapacity must be provided to insured within 31 days of when child reaches limiting age
Newborn child coverage
all policies that provide family coverage must provide certain benefits to newborn children from the moment of birth.
Major Medical Expense premiums vary depending on
amount of deductible, coinsurance percentage, stop-loss amount, maximum amount of the benefit
how can physician or hospital join PPOs
any physician or hospital that qualifies and agrees to follow PPOs standards and charge appropriate fees can be added to the approved list at any time.
how long does insurer have to contest fraudulent misstatements Meade in a health insurance contract
as long as policy in force
HMO open network or closed
closed network - only provide services for people in geographic area
temporary license period cannot exceed
commissioner may issue a temporary license not to exceed 180 days
Major Medical Expense common limitations
covered or eligible expense plans cover most medical expenses in and out of hospital, and have high maximum Benefit limits.
Major Medical Expense Contract deductible
deductibles paid upfront
what dependents are eligible for coverage after 26
disabled dependents who provide proof of incapacity to the insurer within 31 days of reaching limiting age.
HMO emergency care
emergency care provided in and out of service area but preferred in service area.
HIPAA guaranteed issue
employer must offer coverage on a guaranteed issue basis
PPO payments
fee for service
penalty for an unlicensed person impersonating an agent, broker or adjuster
fine of 10-100$
violation for any agent trying to obtain premium payments by fraud representations
fine of 100-1,000
penalty for knowingly paying an unlicensed person acting as producer
fine of 50-500$
penalty for engaging in unfair or deceptive acts in connection with insurance transactions
fine up to 1,000 per act
Patient Protection and Affordable Care Act
health care reform law passed in 2010 that includes incentives and penalties for employers providing health insurance as a benefit. Mandated increased preventative, educational, and community based health care services.
open enrollment period
health care service providers may provide an annual open enrollment period, where individuals may enroll regardless of health
Major Medical Expense Contract Characteristics
high max limits, blanket coverage, coinsurance and a deductible.
the higher the stop loss, the ----- the premium will be.
higher stop loss is lower premium
Essencial Benefits of marketplace health plans
hospitalization, maternity, emergency services, chronic disease management
Appeal Rights (ACA)
if insurers rescind individual or group coverage for reasons of fraud or intentional misrepresentation by the insured, they must provide at least 30 days advance notice to allow insured time to appeal.
BC/BS Reimbursement of providers
if member receives care outside of commonwealth, the plan will make payment to nonparticipating provider, but the amount of reimbursement may be limited to an amount less than the amount billed to the subscriber.
Blue Cross/Blue Shield Associations
independent, nonprofit, voluntary membership organization formed for the purpose of prepaying hospital, medical care, physicians and surgical expenses for its members.
HIPAA credible coverage
insured must be given a day for day credit for previous health coverage against the application of pre-existing condition exclusion period when moving from one group health plan to another or from group to individual
HIPAA Pre-Existing Conditions apply to
large group insurance, NOT individual or small group health insurance
the smaller the percentage that the company pays for coinsurance, the ------ the premium will be.
less
Special Broker
licensed to negotiate, continue or renew insurance contracts with non-admitted foreign insurers.
specified coverage
limits coverage to one illness or one limiting group of coverages. i.e cancer policies, prescription drug coverage, dental plans
Regular basic medical expense policies characterized by
low dollar limits and first dollar coverage, but no protection against catastrophic events
Higher Deductible = -------- premium
lower. if you accept more risk through a higher deductible, the insurance company lowers your premium
Major Medical Expense deductibles
most companies incorporate annual deductible into major medical policy. could range from $100-$2500
Mass eligibility requirements: Dependent Child age Limit
must provide benefits up to age 26
HIPAA Eligibility
nondiscriminatory based on health factors including: > health status > medical conditions > claims experience > receipt of health care > medical history > genetic info > disability > evidence of insurability
Coinsurance
once deductible is met, the insured and insurance company share expenses through coinsurance. Generally, insurance company pays larger portion.
comprehensive care
package of healthcare services. Typically includes preventative care, routine physicals, immunizations, outpatient services, and hospitalizations, such as HMOs
Major Medical Expense Contract coinsurance
paid after deductible is met and claim is submitted
BC/BS contracts with insureds and providers
participating hospitals and doctors agree to accept payment on a predetermined fee schedule and bill plan directly for services provided to members.
HMO payment
prepaid basis - HMO receives flat amount each month attributed to each member
cost saving services (case management provisions)
provide plans with controlled access to providers, large claim management, preventative care, hospitalization alternatives, second surgical opinions, preadmission testing, catastrophic case management, risk sharing, high quality care.
Major Medical Policy designed to do what? How is it made affordable?
provide protection against catastrophic events. By using deductibles and coinsurance, It is made affordable because the policy did not respond to small claims.
fee-for-service
providers are paid for specific care they provide
prepaid plan
providers compensated regularly whether they provide treatment or not
main goal of HMO
reduce the cost of health care by utilizing preventative care.
appeal
request for a higher authority to review decision
Coinsurance helps to keep cost down by
requiring insureds participation in ongoing expense
who is exempt from PPACA
retiree-only, stand alone dental plans, medigap, long term care insurance
benefit schedule
specifically states exactly what is covered in the plan and for how much
concurrent review
the insurance company will monitor the insured's hospital stay to make sure that everything is proceeding according to schedule and that the insured will be released from the hospital as planned
Usual/reasonable/customary
the insurance company will pay an amount for a given procedure based upon the average charge for that procedure in that specific geographic area.
deductible
the portion of medical expenses that are paid by the insured each year before the insurance benefits start.
seeing a specialist in HMO
their primary care physician refers member. This helps keep the member from high priced specialists. There is a financial cost to PCP if they refer patient to more expensive specialist
Newborn child coverage mandatory benefits
treatment of medically diagnosed congenital defects, birth abnormalities and nursery care for injured or sick newborns, special medical formulas prescribed by a physician and approved by commissioner and screening for lead poisoning.
why is HMO plan unique
unique because the HMO provides both the financing and patient care for its members. traditionally insurance company provides financing and doctors provide services
insurance exchanges
will administer health insurance subsidies and facilitate enrollment in private insurance, medicaid and the children's health insurance program
within how many days of any initial pretrial hearing date, must a producer report to the commissioner any criminal persecution against that producer then in any jurisdiction.
within 30 days