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