Insurance - Types of Health Insurance Policies

What are the 3 types of coverages in Basic Medical Insurance?

1. Hospital expense - only covers room and board 2. Medical expenses - nonsurgical services, in-hospital physician visits 3. Surgical expenses - scheduled operations - a list of all operations and the dollar amount. Can purchase individually or all three

at what age is an adult child of the insured eligible until?

26

To convert group health to individual insurance, how soon must it be initiated after termination?

31 days

Under COBRA, for events such as death or divorce, how long must coverage be extended for dependents? Under COBRA, for events such as death or divorce, how long must coverage be extended for dependents?

36 months

How many days after the accident must the death occur within for the accidental death benefit to be paid?

90 days

Capital Sum

A percentage of the principle sum that is paid sometimes

cafeteria plan

A selection of health care benefits from which an employee may choose the ones that he/she needs.

These policies are limited to providing coverage for death, dismemberment, disability, or care resulting from an accident. it will only pay for losses resulting from accidents, not sickness

Accident-Only

What information are the members of the Medical Information Bureau required to report?

Adverse medical information about eh applicants or insured

The offer and acceptance of a legal contract is

Agreement

What is the term used for a written request for an insurer to issue an insurance contract based on the provided information?

Application

What is the term used for an applicant's written request to an insurer for the company to issue a contract, based on the information provided?

Application

In an underwriter requires extensive information about the applicants medical history, what report will best serve this purpose?

Attending physician's statement

Hospital expense policies cover hospital room and board, and sometimes miscellaneous hospital expenses, such as lab and x-ray charges, medicines, use of operating room and supplies, while the insured is confined in a hospital

Basic Hospital Expense Coverage

This is often referred to as Basic Physicians Nonsurgical Expense Coverage because it provides coverage for nonsurgical services a physician provides.

Basic Medical Expense Coverage

What plans do not have a deductible or coinsurance?

Basic Medical Insurance

This coverage is commonly written in conjunction with Hospital Expense policies. THese policies pay for the costs of surgeon's services, whether the surgery performed in or out of the hospital.

Basic Surgical Expense Coverage

This refers to the length of time over which the disability payments will last for each disability

Benefit Period

What are the policy features of Major Medical Insurance?

Blanket limit (overall limit) and lifetime per person limit. deductibles (out of pocket, paid first) and coinsurance (sharing of remaining of the claim) Large benefit maximums

This is a unique type of insurance policy that is sold to small business owners who must continue to meet overhead expenses following a disability

Business Overhead Expenses (BOE)

This requires any employer with 20 or more employees to extend group health coverage to terminated employees and their families after a qualifying event such as, voluntary termination, termination other than gross misconduct, employment status change.

COBRA

These cover only one illness: cancer, and pay a lump-sum when insured is first diagnosed with it

Cancer Policies

What is the Agents responsibility

Compare benefits, limitations and exclusions found in the current and proposed replacement policy Ensure that the current policy is not canceled before new policy is issued

What is Major Medical Insurance called?

Comprehensive Insurance - Offers a broad range of coverages

Comprehensive Major Medical Policies

Comprehensive major medical plans cover nearly all medical expenses with a single policy, including: hospital charges, physician expenses, nursing care, medications, diagnostic and laboratory services. These types of policies generally incorporate deductibles and co-insurance, which help to keep the costs of premiums down by requiring the policyholder to help with the payment for services. However, some policies incorporate what is known as first dollar coverage, which means there is no

An insurance contract requires that both the insured and the insurer meet certain conditions in order for the contract to be enforceable.

Conditional

When an insured makes a truthful statement on the application for insurance and pays the required premium it is called?

Consideration

What reports will provide the underwriter with the information about the insurance applicants credit?

Consumer Report

Utilization management

Controls health care costs and the quality of health care by reviewing cases for appropriateness and medical necessity. Cost Containment

In HMOs and PPOs, managed care plans are designed to control cost by doing what?

Cost containment - controlling behavior of the plan participants such as controlled access of providers, large claim management, preventive care

This policy covers multiple illnesses, such as heart attack, stroke, renal failure, and pays a lump-sum benefit to the insured upon the diagnoses and survival of any of the illnesses covered by the policy. Insured must survive

Critical Illness

This is care for meeting personal needs such as assistance in eating, dressing, or bathing, which can be provided by nonmedical personnel, such as relatives or home health care workers

Custodial Care

This insurance is a form of medical expense health insurance that covers the treatment, care and prevention of dental disease and injury to insureds teeth

Dental Expense

This specifies who will purchase a disabled partner's interest and legally obligates that person or party to purchase such interest upon disability

Disability Buyout Agreement

This is designed to replace lost income in the event of a disability

Disability Income Insurance

A waiting period imposed on insured from the onset of disability until payments commence

Elimination Period

In an insurance contract what is Aleatory?

Exchange of unequal amounts

T/F Pediatric Dental Coverage for children is optional

False; must for 18 or younger

This is a form of cafeteria plan benefit funded by salary reduction and employee contributions. employees can deposit certain amount in2 account before paying taxes, then can be directly reimbursed from it for eligible health care

Flexible Spending Account

What organization is on a prepaid basis

HMOs

What organization uses a network of physicians on a salary

HMOs

THese are designed to help individuals save for qualified health expenses that they, their spouse, or their dependents incur. To use this, an individual must be covered by a HDHP and not covered by any other health insurance

Health Savings Accounts

These are often used in coordination with MSAs, HSAs, or HRAs. it features higher annual deductibles and out of pocket limits than traditional health plans

High-Deductible Health Plans (HDHPs)

This is provided in the insured's home under a planned program established by his or her attending physician. This must be provided by a long-term facility

Home Convalescent Care

This is care provided by a skilled nursing or other professional services in ones home

Home Health Care

This policy provides a specific amount on a daily, weekly, or monthly basis while the insured is confined to a hospital. Based purely on # of days confined at hospital

Hospital Indemnity

What entities make up the Medical Information Bureau?

Insurers

This is occasional nursing or rehabilitative care provided for stable conditions that require daily medical assistance on a less frequent basis than skilled nursing care

Intermediate Care

This policy defines the specific risk in which accidental death or dismemberment benefits will be paid

Limited Risk Policy

These policies provide coverage for individuals who are no longer able to live an independent lifestyle and require living assistance at home or in a nursing home facility. This must provide coverage for at least 12 consecutive months

Long-Term Care Policies

These policies offer a broad range of health coverage under one policy

Major Medical Policies

Basic hospital, surgical, and medical policies and major medical policies are collectively called?

Medical Expense Insurance

In a legal contract what is the consideration?

On the part of the insured - Premiums and representations On the part of the insurer - payments of claims

Unilateral Aleatory

Only one of the parties to the contract is legally bound to do anything. Ex. as long as premium is paid insurer must pay (Dealth)

This is merely a combination of HMO and PPO plans

POS (Point-Of-Service)

What organization is a fee for service

PPO

traditional medical systems' answer to HMO's, this is a group of physicians and hospitals that contract with employers, insurers, or third party organizations to provide medical care services at a reduced fee

PPO (Preferred Provider Organizations)

This is a provision in disability income policies that lists conditions which will automatically qualify a guy for full disability benefits

Presumptive Disability

Also known as a gatekeeper, this individual becomes the main individual responsible for the care of an HMO member

Primary Care Physician

This is another type of waiting period that is imposed under some disability income policies that adds onto the elimination period

Probationary Period

What are three types of Utilization management in an HMO plan

Prospective review - You need a referral from your PCP to see a specialist Concurrent Review - Make sure you don't need to be in the hospital longer than necessary Retrospective Review - reviewing what doctors are doing and the outcomes to see if they could have done something cheaper

This is a provision in disability income policies that specifies the period of time during which the recurrence of an injury or illness

Recurrent Disability

The Federal Fair Credit Reporting Act

Regulates consumer reports

When this approach is used, each surgical procedure will be assigned a number of points, that are relative to the number of points assigned to the max benefit

Relative Value

This is provided while the insured resides in a retirement community or a residential care facility for the elderly. Same freedom as living at home

Residential Care

These insurance plans are designed to provide temporary coverage for people in transition (jobs/retirees) and are available for terms from one month to 11 months

Short-Term Medical Insurance Plans

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

Skilled Care

This policy will cover unusual types of risks that are not normally covered under AD&D policies

Special Risk Policy

What are the two types of major medical policies

Supplemental Major Medical Policies and Comprehensive Major Medical Policies

This is attached to the Basic Surgical Expense Coverage contract and lists the types of operations covered and their assigned dollar amounts

Surgical Schedule

This is care provided for functionally impaired adults on less than a 24-hour basis. Could be provided by neighborhood rec or community center

T Adult Day Care

What is the entire contract in health insurance underwriting?

The application and the policy issued

On a health insurance application, a signature is required from?

The policyowner, the agent, the proposed insured

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

T/F Most Long term care policies are gauranteed renewable

True; the insurer can increase premium tho

Employer-Sponsored Group Association Group

Two types of groups eligible for group insurance?(must be formed for other purpose than simply obtaining group insurance)

Preferred Provider Organization (PPO)

a group of doctors and hospitals that agree to provide health care at rates approved by the insurer fee-for-service no PCP referrals

Riders

added to the basic insurance policy to add, modify or delete policy provisions

When one party prepares the contract and then the other party must accept it this is referred to as?

adhesion

What does it mean when you see Usual, Customary, and Reasonable

amount paid for procedure based upon average charge in that specific geographic area

Conditional Aleatory

certain conditions must be met ex. Premium paid and proof of loss in order for insurer to pay

What does Major Medical Insurance Cover?

expenses associated with routine types of medical care, such as physician office visits, medications, ambulance care, etc. Comprehensive coverage for hospital expenses Catastrophic medical expenses like open heart surgery Benefits for long-term injury or illness

comprehensive coverage

health insurance that provides coverage for most types of medical expenses

Indemnity Plan

pays health policy benefits to the insured based on a predetermined, fixed rate, regardless of the actual expense incurred

what are HMOs (health maintenance organizations) cost saving services?

preventative health care. outpatient benefits - surgeries you don't have to stay overnight in a hospital Alternative care

Underwriting

risk selection and classification process

benefit schedule

specifically states exactly what is covered in the plan and for how much. Anytime you see schedule it means list

people who are covered by an HMOs are called?

subscriber Insured is referred to with the other major medical plans

nonrenewable

termination of an insurance policy at its expiration date by not offering a continuation of the existing policy or a replacement policy

capitation fee

the fee or premium paid in advance to the HMO Per head fee

adverse

unfavorable

Under COBRA, how long must coverage normally be extended?

up to 18 months