[2/7]21% Types of Health Policies

An employee insured under a group health plan has been paying $25 monthly premium for his group health coverage. The employer has been contributing $75, for the total monthly cost of $100. If the employee leaves the company, what would be his maximum monthly premium for COBRA coverage?

$102

COBRA: Length of Coverage

* 18 months - After qualifying event * 36 months - for dependents after events such as death of the employee, divorce or legal separation

Flexible Spending Account (FSA)

-Funded by salary reduction and employer contributions -Employees deposit pre-tax funds into an account. During the year, the employee is reimbursed from this account from eligible health care and dependent care expenses. -FSA benefits are subject to annual maximum and "Use-or-lose" rule

Preferred Provider Organizations (PPOs)

-Group of physicians and hospitals that contract to provide medical care services at reduced fee. -Members can use any physician they choose, but are encouraged to use approved physicians who have previously agreed upon fees.

Health Maintenance Organization (HMOs)

-Preventive care -Limited -Limited choice to providers -Copayments -Prepaid basis -Primary Care Physician (PCP): serves as a gatekeeper -Referral (Specialty) Physician: PCP's referral required

Two types of Major Medical Policies?

-Supplemental Major medical policies -Comprehensive Major Medical policies

High-deductible Health Plans (HDHPs)

-Used in coordination with MSAs, HSAs, or HRAs. -Features higher annual deductibles and out-of-pocket limits than traditional health plans, which means lower premiums.

Types of: LIMITED BENEFIT PLANS

-accident -dread disease -critical illness -employer-sponsored -Hospital indemnity -Dental -Short-term medical -Vision/hearing

Long-Term Care

-available as individual policies group policies or as rider to life insurance policies -coverage for individuals who require living assistance at home or in nursing home -guaranteed renewable, but insurers may increase premiums

Point-of-Service plans (POS)

-combination of HMO and PPO plans -Employees not locked into one plan; allowed to choose depending on the need for medical services

Major medical policies offers a range of coverage (lifetime benefit per person limit) under one policy:

-comprehensive coverage of hospital expenses -catastrophic medical expense protection -Benefits for prolonged injury or illness

Accidental Death and Dismemberment

-only pays for accidental losses -is considered a pure form of a accident insurance -principal sum paid for accidental death -capital sum paid for dismemberment

COBRA: Qualifying Events

-voluntary termination of employment -Termination of employment for reasons other than gross misconduct -Employment status change: from full time to part time

(4) types of Medical expense Insurance

1.Basic hospital expense coverage 2.Miscellaneous hospital expenses 3. Basic medical expense coverage 4. Basic surgical expense coverage

What offers a range of coverage (lifetime benefit per person limit) under one plicy?

Major medical policies

An insured is covered by a disability income policy that contains an accidental means clause. The insured exits a bus by jumping down the steps and breaks an ankle. What coverage will apply?

No coverage will apply, since the injury could have been foreseen.

Intermediate care

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

Comprehensive Major Medical Policies

This is a combination of basic coverage and major medical coverage that features low deductibles, high maximum benefits, and coinsurance.

How is emergency care covered for a member of an HMO?

a member of an HMO can receive care in or out of the HMO service area, but care is preferred in the service area.

Dread Disease Policy

a variety of benefits for a specific disease such as cancer policy or heart disease policy

Occasional visits by which of the following medical professionals will NOT be covered under LTC's home health care? a) Attending physician b) registered nurse c) Licensed practical nurses d) community-based organizations

a) Attending physician

Which of the following is considered a qualifying event under COBRA a) divorce b) marriage c) relocation d) promotion

a) divorce

Which of the following is NOT true of a major-medical health insurance policy? a) it is designed to pay on a first dollar of expense basis b) it usually has a maximum benefit amount c) the benefits are subject to deductibles d) It is designed to cover hospital and medical expenses of a catastrophic nature.

a) it is designed to pay on a first dollar of expense basis

All of the following long term care coverages would allow an insured to receive care at home EXCEPT? a) skilled care b) custodial care in insured house c) respite care d) home health care

a) skilled care

An employee becomes insured under a PPO plan provided by his employer. If the insured decides to go to a physician who is not a PPO provider, which of the following will happen? a) the PPO will pay reduced benefits b) the PPO will not pay any benefits at all c) the insured will be required to pay a higher deductible d) the PPO will pay the same benefits as if the insured had seen a PPO physician

a) the PPO will pay reduced benefits

Supplemental Major Medical Polices

are used to supplement that coverage payable under a basic medical expense policy. After the basic policy pays, the supplemental major medical will provide coverage for expenses that were not covered by basic policy, and expenses that exceed the maximum. If the time limitation is used up in the basic policy, the supplemental coverage will provide coverage thereafer

How can a new physician be added to the PPO's approved list? a) New physician are only added once a year, and are selected by the PPO's Board of Directors b) Agree to follow the PPO standard and charge the appropriate fees c) Fill out the appropriate paper work and wait the 12 month pre-certification period. d) Pay an annual fee for being on the PPO list.

b) agree to follow the PPO standard and charge the appropriate fees

Regarding long-term care coverage, as the elimination period gets shorter, the premium? a) get lower b) gets higher c) remains constant d) premiums are not based on elimination periods

b) get higher

Don has both a basic expense and a major medical policy. He is injured in an accident, which requires several major surgeries. This quickly exhausts Don's basic expense policy. What must Don do before his major medical policy can pick up where the basic expense policy left off? a) submit written notification to his major medical insurance company b) pay a special deductible on his major medical policy c) wait 6 months in order to be covered again d) nothing needs to be done.

b) pay a special deductible on his major medical policy

Which of the following is NOT covered under Basic Hospital Expense Coverage? a) x-ray charges b) surgeons fees c) hospital room and board d) Lab charges

b) surgeons fees

How many consecutive months of coverage must LTC insurance provide in this state? a) 36 b) 6 c) 12 d) 24

c) 12

An insured is involved in an accident that renders him permanently deaf, although he does not sustain any other major injuries. The insured is still able to perform his current job. To what extent will he receive Presumptive Disability benefits? a) full benefit for 2 years b) no benefits c) full benefit d) partial benefits

c) full benefit

In long term care insurance, what type of care is provided with intermediate care? a) daily care, but not nursing home b) intensive care c) occasional nursing or rehabilitative care d) nonmedical daily care

c) occasional nursing or rehabilitate care

Custodial care

care for a person's activities of daily living provided in an institutional setting or in the patients home

Dental plans

cover the treatment, care and prevention of dental disease and injury to the insured's teeth

Accident

coverage for disability, medical care, death or dismemberment resulting form an accident

Basic surgical expense coverage

covers cost of surgeons services, wether the surgery is performed in or out of the hospital.

1. Basic hospital expense coverage

covers hospital room and board, and miscellaneous expenses, such as lab and x-ray charges and medicines while insured is confined to hospital.

Which of the following is a feature of a disability buyout plan? a) tax deductible premiums b) taxable benefits c) a short elimination period d) a lump sum benefit payment option

d) a lump sum benefit payment option

Which of the following long-term care benefits would provide coverage for care of functionally impaired adults on a less than 24 hour basis? a) residential care b) assisted living c) home health care d) adult day care

d) adult day care

A small company offers group health insurance to its employees, but recently has decided to terminate the health insurance contract, leaving the workers without insurance. What can the employees do regarding their insurance? a) sue the employer b) apply for another group health insurance c) request a refund of unearned premium d) convert to an individual health policy

d) conver to an individual health policy

Skilled care

daily nursing and rehabilitative care provided by medical personnel

Employer sponsored plan

employer provided group coverage ; employees must meet service requirements and work full time

Health Saving accounts (HSAs)

individuals covered by a high deductible health plan can make a tax-deductible contribution to an HSA, and use it to pay for out-of-pocket medical expenses.

Benefit period

length of time monthly disability benefit payments las

Benefit limitations

maximum benefits an insurer is willing to accept for an individual risk; based on percentage of insured's past earning

Critical illness

pays a lump sum to the insured upon diagnosis and survival of a critical illness

Miscellaneous hospital expenses

pays for other miscellaneous expenses associated with a hospital stay; expressed either as a multiple of the room and board charge or as a flat amount.

probationary period

period after the policy starts during which benefits won't be paid for illness related disabilities

Regarding the taxation of Business Overhead policies,

premiums are deductible and benefits are taxed

Home Convalescent Care

provided by a long-term care facility, a home health care agency or a hospital in the insured's home under a planned program established by his or her attending physician

Home heath care

provided by registered nurses, licensed practical nurses, licensed vocational nurses, or community based organization like hospice in one's home

Residential Care

provided while the insured resides in a retirement community

Hospital indemnity

provides a specific amount on a daily, weekly or monthly basis while the insured is confined to a hospital

Basic medical expense coverage

provides coverage for nonsurgical physician's services. Also can be purchased to cover emergency accident benefits, maternity benefits, mental and nervous disorders, hospice care, home health care, out patient care, and nurses' expenses.

Respite care

provides relief to the family caregiver; adult day care centers may also provide this type of relief

Business Overhead Expense policy

reimburses small business owners of overhead expenses incurred while the business owner is totaly disabled

Presumptive disability

specifies condition that qualify insured for full disability benefits

Recurrent Disability

specifies period of time during with the recurrence of an injury or illness will be considered a continuation of a prior disability

Business disability Buyout policy

specifies who will purchase a business partner's interest in case of disability

Social insurance Supplement (SIS)

supplement or replace benefits payable under social Security Disability

Short-Term medical

temporary coverage for people in transition

Vision/hearing plans

type of group health insurance that covers eye examinations and eyeglasses, or hearing aid on a limited basis.

Elimination period

waiting period that last from the onset of disability until benefit payments start