Chapter 10

the FMLA states:

- An eligible employee is entitled to 12 weeks of unpaid leave for 3 reasons: 1. Because of the birth, adoption, or foster care 2. serious health condition of spouse, child, or parent 3. employees own serious health condition

Health Maintenance Organizations (HMOs)

- Provides prepare medical services -fixed periodic enrollment fees cover HMO members for all medically necessary services only if the services are delivered by health care providers in the designated network and approved by the HMO. HMOs generally provide inpatient and outpatient care, emergency room care, as well as services from physicians, surgeons, and other health care professionals. Most medical services are either fully covered or, in the case of some HMOs, participants are required to make copayments

List the FMLA Revision in 2009

- These changes create leave opportunities for the military and require employees to adhere to stricter guidelines for taking leave. - Relatives of seriously injured members of the military may take up 26 weeks off to care for their injured military family members. - Relative of members of the National Guard or reserves who are called to active duty may receive up to 12 weeks of leave to attend military programs (official send off of the members' troop ) , arrange child care or make financial arrangements.

Point of service plans

- combine feature of HMOs and fee for service - employees pay a nominal copayment for each visit to a designated network of physicians - Employees possess the option to receive care from health care providers outside the designated network of physicians, but they pay somewhat more for this choice

Cadillac Tax

-will apply to high-cost employer-sponsored health plans - implementation delayed until 2020 - health plans that exceed designated dollar amounts will be required to pay a tax equal to 40 percent of the amount that exceeds the designated dollar amounts. - The tax was intended to be a disincentive for employers to provide overly rich health benefits

4 common managed care plans :

1. Health Maintenance Organizations (HMOs) 2. Exclusive Provider Organizations (EPOs) 3. Preferred Provider Organizations (PPOs) 4. Point-of-service (POS) plans

There are 4 categories of legally required benefits:

1. Social Security Programs 2. Workers' Compensation 3. Family and Medical Leave 4. Health Insurance

The age for collecting full Social Security benefits is gradually increasing to age ___ in 2022.

67

Exclusive provider organization (EPO)

A variation of a ppo more restrictive does not require a primary care physician

To be eligible for unemployment insurance benefits, an individual must: A. Not have left a job voluntarily B. Be able and available for work C. Be Actively Seeking work D. Not have refused an offer of suitable employment E. Not be unemployed because of a labor dispute F. Not have had employment terminated because of gross violations of conduct within the workplace.

A,B,C,D,E,F

The SSA calculates survivors' benefits based on the insureds' employment status and the survivors' relationship to the deceased. Which of the following are appropriate? A. Dependent, unmarried children of the deceased B. Deceased was fully insured C. Spouse of the deceased was caring for a child D. Widower at least age 60 or 62 if widower was dependent on the deceased employee.

ABCD

Participation in workers' compensation programs is compulsory in all states EXCEPT A. Texas B. New Jersey C. Oklahoma D. All of the above

All of the above are not required to provide workers compensation insurance.

The minimum criteria for eligibility under FMLA includes: A. eligible workers must be employed by a private employer or by a civilian unit of the fed govt B. must have been employees for at least 12 months by a given employer. C. Eligible workers have provided at least 1,250 hours of strive during the 12 months prior to making a request to leave D. all of the above

D employees who do not meet these criteria are excluded, as are those who work for an employer with were than 50 employees.

Health care plans share a few features in common. These include:

Deductible Coinsurance Out-of-Pocket Maximum Preexisting Condition Clauses Lifetime and Yearly Limits

Managed care plans became popular alternatives to fee-for-service plans mainly to help control the costs of health care. As has been discussed, managed care plans by design impose substantial restrictions on an employee's ability to make choices about from whom they could receive medical treatment, the gatekeeper role of primary care physicians, and the level of benefits they could receive based on designated in- and non-network providers.

Despite these cost-control objectives, health care costs have continued to rise dramatically over the years while also restricting employee choice.

The _________________________________________ aims to provide employees with job protection in cases of family or medical emergency.

Family and Medical Leave Act of 1993 (FMLA)

PPACA distinguishes between health plans that existed prior to March 23, 2010, enactment date and those that come into existence afterward. Individual and group health plans already in existence prior to enactment are referred to as ________ plans.

Grandfathered plans

The ____________________________ emphasizes cost control by limiting an employee's choice of doctors and hospitals.

Managed-care approach

_______________________________________, a select group of health care providers agrees to furnish health care services to a given population at a lower level of reimbursement than is the case for fee-for-service plans.

Preferred Provider Organization (PPO)

The medicare program includes 5 separate features: Medicare Part A - Hospital Insurance (covers both inpatient and outpatient hospital care and services) Medicare Part B- Medical Insurance (covers 80% of medical services and supplies like outpatient care, laboratory test) **Medicare provides this coverage. Part b is optional. You have your choice of doctors. Medigap- voluntary supplemental insurance to pay for services not covered by a and b **you can choose to buy this private coverage to fill in gaps of part a and b coverage. Medicare Part C- choices in health care providers, such as through HMOs and PPOs **Private insurance companies approved by Medicare provide this coverage. Medicare Part D- prescription drug coverage **you can choose this coverage. private companies approved by medicare run these plans.

The ORIGINAL MEDICARE PLAN includes PART A (HOSPITAL), PART B(MEDICAL), PART D (DRUGS), AND MEDIGAP. The MEDICARE ADVANTAGE PLANS LIKE HMOs and PPOs (CALLED PART C) which combines part a and part b. plus part d (dugs)

The social security act establishes the following programs: A. Unemployment Insurance B. Old, Age, Survivor, and Disability Insurance (OASDI) C. Medicare D. All of the Above

The Social Security Act established Unemployment Insurance, OASDI, and Medicare.

Employers may consider using two other health accounts to help defray the costs of medical care: health reimbursement arrangements and flexible spending accounts. Employers establish health reimbursement arrangements (HRAs) that reimburse employees for health care expenses. Only the employer is permitted to fund HRAs and there is no allowable maximum contribution limit. As with HSAs, employees can carry over unused balances into subsequent years.

The establishment of flexible spending accounts preceded the era of consumer-driven health care by decades. The IRS established flexible spending accounts in the 1970s as part of flexible benefit plans because employers were increasing the annual deductible amounts and coinsurance rates in response to higher health plan premiums. These increases were proving to be particularly burdensome to employees. Flexible spending accounts (FSAs) permit employees to pay for specified health care costs that are not covered by an employer's insurance plan. Prior to each plan year, employees elect the amount of pay they wish to allocate to this kind of plan. Employers then use these moneys to reimburse employees for expenses incurred during the plan year that qualify for repayment.

The idea of consumer-driven health care received substantially greater attention than ever before under the Bush administration (President George W. Bush) and the Republican-led Congress, who favored greater employee involvement in their medical care and reductions in the cost burden for companies to help maintain competitiveness in the global market. The Medicare Prescription Drug, Improvement and Modernization Act of 2003 added section 223 to the IRC, effective January 1, 2004, to permit most companies to establish health savings accounts (HSAs) for employees who are enrolled in an HDHP to help pay for medical expenses. It is important to note that HSAs are not available for any other type of health care plan.

The sum of an employer's and employee's contribution to an HSA cannot exceed the high-deductible health plan's annual deductible. Employers may require employees to contribute to these limits. An unused balance at the end of the year carries over to the next year and the employee owns the account and its holdings following termination or retirement from the company. Beginning at age 65, HSA holders may use these funds for retirement income.

Individuals may receive various benefit levels upon retirement, or under survivors' and disability programs, based on how much credit they have earned through eligible contributions. They earn credit based on quarters of coverage, which refers to each 3-month period of employment during which an employee contributes to the retirement income program under the Social Security Act of 1935

True

Legally required benefits historically provided a form of social insurance. (T/F)

True

The Patient Protection and Affordable Care Act of 2010 now required employers to offer health insurance to their employees. (T/F)

True

Today, legally required benefits represent a significant cost to companies. In 2017, companies spent an annual average of $5,470 per employee to provide legally required benefits. It accounted for 7.9% of the employers' total payroll cost. (T/F)

True

Unemployment Insurance is for individuals who became unemployed through no fault of their own. (T/F)

True

Unemployment itself does not necessarily qualify a person, although these criteria vary somewhat by state. (T/F)

True

Prompted largely by the rapid growth of industrialization in the United States in the early 19th century and the Great Depression of the 1930s, initial social insurance programs were designed to minimize the possibility that individuals who become unemployed or severely injured while working would become destitute.

True the reason why initial social insurance programs were designed was because of the rapid growth of industrialization and Great Depression. They aimed to reduce the possibility of extreme poverty for those who got sick or unemployed.

Workers' compensation differs from Social Security disability insurance and Medicare in 2 important ways which of the following is correct? A. Workers compensation pays for medical care for work-related injuries beginning immediately after the injury occurs;it pays temporary disability benefits after a waiting period of three to seven days; it pays permanent partial and permanent total disability benefits to workers who have lasting consequences of disabilities caused on the job; B. Social Security pays benefits to workers with long-term disabilities from any cause, but only when the disabilities preclude work. Social Security also pays for rehabilitation services and for survivor benefits to families of deceased workers. Social Security begins after a five-month waiting period C. Medicare begins 29 months after the onset of medically verified inability to work. D. all of the above

all of above

Which of the following are health insurance program design alternatives? A. Fee-for-service plans B. Managed Care Approaches C. Plans associated with the Consumer-driven health care approach D. all of the above

all of the abobe

Which of the following are objectives of workers' compensation laws? A. Provide income and medical benefits to work accident victims or income benefits to their dependents, regardless of fault. B. Reduce litigation (provide a single remedy & reduce court delays) C. Relieve charities financial drain D. Eliminate legal fees and times E. Encourage employer interest in safety F. Promote accident study and avoidance

all of the above

Which of the following is true ? Companies that fail to offer health care plans are subject to a penalty. The penalty is larger if the company fails to offer affordable, minimum-value coverage. Oftentimes, a company's decision whether to offer health care plans is called "pay or play." Companies that do not offer health-care plans or ones that follow the minimum standards specified in the PPACA must pay. Those that offer health care plans that meet or exceed minimum standards are said to play. all of the above

all of the above

preexisting condition clauses

condition for which medical advice, diagnosis, care, or treatment was received or recommended during a designated period preceding the beginning of coverage.

___________________________________________ approach refers to the objective of helping companies maintain control over costs while also enabling employees to make wise choices about their health care

consumer-drive health care plan CDHP enables employers to lower the cost of insurance premiums by selecting plans with higher employee deductibles.

The Patient Protection and Affordable Care Act of 2010 (PPACA) is a. comprehensive law that mandates health insurance coverage b. sets minimum standards for insurance c. mandates that companies with at least 50 employees offer affordable health insurance under the law d. all of the above

d. all of the above

What exactly distinguishes an HDHP from traditional health care plans?

deductible and out-of-pocket maximums.

Physicians qualify as preferred providers by: - meeting quality standards, - agreeing to follow cost containment procedures implemented by the PPO, and - accepting the PPO's reimbursement structure.

does not provide prepaid benefits

FLMA revisions in 2015

expanded definition of spouse to include individual in legal same-sex marriages

Single coverage:

extends benefits ONLY to the covered employee

3 types of eligible health expenses are :

hospital expenses surgical expenses physician expenses

An ______________________ refers to a contractual relationship between the insurance company and the beneficiary. It specifies the amount of money that the insurance company will pay for such particular services as physical examinations.

insurance policy

Deductible

is an amount an insured must pay for services before health insurance benefits become active.

lifetime and yearly limits

lifetime limits refer to the max amount a plan would include if a person receives coverage. not permitted since ppaca yearly limits refers to the max amount a plan would cover each year. also not permitted

Out-of-pocket maximum

limits the total dollar expenditure a beneficiary must pay during any plan year. it protects individuals from catastrophic medical expenses or expenses associate with recurring episodes of the same illness.

Federal Employees' Compensation Act

mandates workers' compensation insurance protection for federal civilian employees.

Longshore and Harbor Workers' Compensation Act

mandates workers' compensation insurance protection for maritime workers

New health plans (or preexisting plans that have been substantially modified after march 23 2010 are referred to as _____________-

nongrandfathered plans

Family Coverage:

offers benefits to the covered employee AND qualified dependents

Coinsurance

percentage of covered expenses paid by the insured. most commercial plans stipulate 20 percent coinsurance. this means that the insured will pay 20 percent of covered expenses, whereas the insurance company pays 80 percent

Employers pay insurance companies a negotiated amount, or __________________, to establish and maintain insurance policies.

premium A premium is the amount of money an individual or company pays to maintain insurance coverage.

A person may receive coverage under the original Medicare Plan or Medicare Advantage Plans t/f

t

An employee must be employed for the last 4 or 5 quarters prior to becoming unemployed, known as base period. t/f

t

Another type of HMO is the open-access HMO. These are prepaid plans and require the use of network health care providers with one exception. In open-access HMO plans, emergency care outside the network is covered, which is not the case for traditional HMO plans. t/f

t

Disability benefits are available to disabled workers who are unable to work because of serious medical or mental impairment that lasts at least 12 months. t/f

t

Employers must fund workers' compensation programs according to state guidelines. t.f

t

Employers often use separate insurance plans to provide specific kinds of benefits. Benefits professionals sometimes refer to these plans as carve-out plans. Carve-out plans are set up to cover dental care, vision care, prescription drugs, mental health and substance abuse, and maternity care. Specialty HMOs or PPOs usually manage carve-out plans based on the expectation that single-specialty practices may control costs more effectively than multispecialty medical practices.

t

Employers usually enter a contractual relationship with one or more insurance companies to provide health-related services for their employees and, if specified, employees' dependents. t/f

t

HMOs assign each member to a primary care physician or require each member to choose one. Primary care physicians determine when patients need the care of specialists. HMOs use primary care physicians to control costs by significantly reducing the number of unnecessary visits to specialists.

t

HMOs require that patients make copayments. Copayments refer to the nominal payments an individual makes as a condition of receiving services.

t

Health Insurance covers the costs of a variety of services that promote sound physical and mental health, including physical examinations, diagnostic testing, surgery, hospitalization, psychotherapy, dental treatments, and corrective prescription lenses for vision deficiencies. t/f

t

In recent years, workers' compensation claims have risen dramatically in terms of both numbers of claims and claim amounts. The increased prevalence of repetitive strain injuries resulting from the use of keyboards has contributed to this trend. In March 2018, workers' compensation cost nearly 18 percent of all legally required benefits t.f

t

Individuals who meet the eligibility criteria receive weekly benefits. Because the federal government places no limits on a maximum allowable amount, the benefits amount varies widely from state to state. t/f

t

Maritime workers within U.S. borders and federal civilian employees are covered by their own workers' compensation programs. t/f

t

Medicare program serves nearly all U.S. citizens age 65 or older by providing insurance coverage for hospitalization, convalescent care, prescription drugs, and major doctor bills. t.f

t

Prescription drug plans cover the costs of drugs. These plans apply exclusively to drugs that state or federal laws require to be dispensed by licensed pharmacists. Prescription drugs dispensed to individuals during hospitalization or treatment in a long-term care facility are not covered by prescription drug plans. Insurance companies specify which prescription drugs are covered, how much they will pay, and the basis for paying for drugs.

t

Reducing or eliminating coverage for one or more "essential benefits" will cause a grandfathered plan to lose this status. Essential health benefits must include items and services within at least the following 10 categories: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care

t

Seriously disabled workers are eligible to receive benefits if they meet 2 criteria: 1. the worker must have accumulated atleast 40 credits (so the worker must be full insured) 2. the worker must have earned at least 20 credits of the last 40 quarters in the last 10 years t.f

t

Some states mandate leave. Paid sick leave has become a requirement in some states. t/f

t

The SSA pays benefits to seriously disabled workers and family members. Social Security pays only for TOTAL disability. Disability under Social Security is based on a person's inability to perform work done before becoming disabled. The disability must also last, or be expected to last, for at least one year or to result in death. T/F

t

The original medicare plan is a fee-for-service plan that is managed by the fed govt t/f

t

There is a variety of health care plan design alternatives. The U.S. Bureau of Labor Statistics provides four questions to help distinguish among them: Is the plan an indemnity or prepaid plan? Indemnity plans reimburse the patient or the provider as medical expenses occur or afterward. Prepaid plans pay medical service providers a fixed amount based on the number of people regardless of services received. Does the plan have a network? A network is a specific group, composed of doctors, hospitals, suppliers, and clinics, that has contracted to provide services for an agreed rate. Does the plan allow people to receive nonemergency care outside the network? This question identifies how restrictive the plan is regarding choice of medical providers. Does the plan have more than two levels of coverage? This question determines if this plan is a point-of-service plan, which generally has several reimbursement levels depending on where enrollees receive services.

t

Under fee-for-service plans, the insured may generally select any licensed physical, surgeon, or medical facility for treatment, and the insurance company reimburses the insured after medical services are rendered.

t

While on leave, employees retain all previously earned seniority or employee benefits, though employees do not have the right to such benefits while on leave. t/f

t

Workers' compensation laws specify the permissible methods of funding. Employers generally subscribe to workers' compensation insurance through private carriers or, in some instances, through state funds. A third funding option, self-insurance, requires companies to deposit a surety bond, enabling them to pay their own workers' claims directly. t/f

t

children can also become seriously ill, requiring parent attention. t/f

t

employers may require employees to use paid personal, sick, or vacation leave FIRST as part of the 12 week period. If an employees paid leave falls short of the 12 week mandated period, then the employer must provide further leave -- unpaid-- to total 12 weeks.

t

grandfathered plans can lose status if they are substantial modifications, for example, the elimination of all or substantially ALL benefits to diagnose or treat particular medical conditions.

t

participants in fee-for-service plans possess the choice to receive care from virtually any licensed health care provider or facility.

t

the FMLA does not explicitly define 'hours of service' as a result some employees have filed lawsuits against employers t/f

t

the FMLA enables fathers to take paternity leave to care for their new born babies. t/f

t

the basic thrust of FMLA is guaranteed leave, and a key element of that guarantee is the right of the employee to return either to the position he or she left when the leave began or to an equivalent position with the same pay, benefits. and other terms and conditions of employment. t/f

t

the passage of the FMLA reflect a growing recognition that employees' parents are becoming older, rendering them susceptible to as serious illness or medical condition. Older parents are likely to required attention for an extended period while ill, which can be difficult for their adult children, t/f

t

until the passage of the FMLA, men did not have protection comparable to what women receive under the pregnancy discrimination act.

t

while on leave, employees are entitle to receive health insurance benefits (FMLA) t/f

t

workers' compensation laws cover virtually all employees in the United States, except for domestic workers, some agricultural workers, and small businesses with fewer than a dozen regular employees. t/f

t

OASDI was enacted in 1935 for retirement insurance, survivors insurance added 1939, and disability and medicare added in in 1965. t/f

t OASDI provides retirement income, survivors insurance, disability insurance and medicare.

Eligibility of disability benefits varies according to age and disability. Younger workers need fewer quarters of coverage because they have fewer years to accumulate quarters. t/f

t`

Workers' compensation programs, run by states individually, are designed to cover expenses incurred in employees' work-related accidents. t.f

t`

An employee who is terminated as part of a company layoff is ELIGIBLE for unemployment insurance. t/f

true

Fee-for-service plans provide protection against health care expenses in the form of a cash benefit paid to the insured or directly to the health care provider after the employee has received health care services.

true

Participation in workers' compensation programs is compulsory in all states EXCEPT for New Jersey, Oklahoma, and Texas, where employers are NOT required to provide workers' compensation insurance. t/f

true

Social Security Programs: (Social Security Act of 1935 provided unemployment insurance and old-age insurance. A 1939 change in the law added survivor benefits and benefits for the retiree's spouse and children. In 1956 disability benefits were added, and, Medicare was added in 1965) T/F

true

The Patient Protection and Affordable Care Act (PPACA), enacted on March 23, 2010, is a comprehensive law that mandates that employers with 50 or more employees offer health insurance to employees. (T/F)

true

Those applying for unemployment insurance benefits must have been employed for a minimum period. This base period is the minimum period of time an individual must be employed before becoming eligible to receive unemployment insurance under the SSA 1935. t/f

true

Unemployment insurance provides temporary income to those individuals who are unemployed due to no fault of their own t/f

true

Workers may earn up to 4 quarters of coverage credit each year. Individuals become fully insured when they earn credit for 40 quarters of coverage or 10 years of employment and remain fully insured for their lifetime t/f

true