Persona Finance Ch. 9
A managed care plan that is similar to a PPO but reimburses members only when affiliated providers are used.
exclusive provider organization (EPO)
Part A: Medicare also covers all or part of the cost of up to ___ days in post-hospital extended-care facilities that provide skilled care, such as nursing homes. However, it doesn't cover the most common types of nursing home care—___ and ___ care.
100 intermediate, custodial
Health insurance premiums have increased ___%, workers earnings have increased ___%, and inflation has increased ___%
119 34 29
If you're laid off from or leave a job where you've had health benefits, then you are legally eligible to continue your coverage for a period of ___ under federal COBRA regulations.
18 months
medicaid expansion and the ACA: -employer requirements: -penalty starts at $___ per employee in excess of ___ -all businesses over ___ full time employees must offer health insurance coverage or pay this fine
2,000, 30 50
About ___ percent of the U.S. population is covered by some form of government health insurance program.
31
social security waiting period is ___ minimum
5 months
in 2012, about ___ percent of all U.S. personal bankruptcies were due, at least in part, to medical costs.
62
coinsurance in which you pay 20% of remaining balance and insurance pays 80% of remaining balance
80/20 coinsurance
Part A: provides inpatient hospital services such as room, board, and other customary inpatient service for the first ___ days of illness. A deductible is applied during the first ___days of illness. Co-insurance provisions, applicable to days ___-___of the hospital stay, can further reduce benefits.
90 60 61-90
The delivery of medical and personal care, other than hospital care, to persons with chronic medical conditions resulting from either illness or frailty.
long-term care
Premiums are increasing because: advanced medical techniques are ___ frivolous ___ lawsuits insurance ____ ___ US population Which is the biggest cause?
expensive malpractice fraud aging aging US population
Managed care plans include: (4)
HMOs PPOs exclusive provider organizations (EPOs) point-of-service (POS) plans.
2 types of high deductible plans:
Health reimbursement account (HRA) Health savings account (HSA)
EPO: Plan members who use a ___ provider must bear the entire cost.
nonaffiliated
___ policies offer guaranteed renewability, but they also guarantee that future premiums will remain the same as those stated in the policy at issuance.
Noncancelable
managed care plan that's like HMOs, but allows you out of network options
PPO
A voluntary program under Medicare that provides payments for services not covered under basic hospital insurance.
Part B- supplementary medical insurance (SMI)
A voluntary program under Medicare. insurance that covers both brand-name and generic prescription drugs at participating pharmacies.
Part D: prescription drug coverage
these plans provide Medicare benefits to eligible people, but they differ in that they are administered by private providers rather than by the government. Common supplemental benefits include vision, hearing, dental, general checkups, and health and wellness programs.
Plan C: medicare advantage plan
Health care reform legislation that requires all Americans to have or buy health insurance, requires insurers to cover the children of those they insure up to the age of 26, prohibits insurers from denying coverage or setting unrealistically high premiums for pre-existing medical conditions, establishes health care insurance exchanges, and requires small firms to provide health insurance coverage for its employees.
The Patient Protection and Affordable Care Act and the Reconciliation Act of 2010
what the insurer considers to be the prevailing fees within your area, not what your doctor or hospital actually charges
UCR charges
social security offers disability benefits, but you must be unable to do __ job. Benefits are payable only if your disability is expected to last at least ___ (or to be fatal), and they don't begin until you've been disabled for at least ___.
any one year 5 months
HMOs: -want you to stay ___ -what you pay: -___ fee (varies w/ fam size) -___ for each service -no ___ or ___
at home monthly co-pay deductible, claim filing
Medicare: Part A covers: Part B: Plan C: Part D:
basic hospital insurance supplementary medical insurance medicare advantage plan prescription drug coverage
Traditionally, Medicare has provided two primary health care components, ___ and ___; in 2006, it began offering ___.
basic hospital insurance supplementary medical insurance prescription drug coverage
Prepaid hospital and medical expense plans under which health care services are provided to plan participants by member hospitals and physicians. not technically insurance policies
blue cross/blue shield plans
group insurance leverages ___ power of a group of people (workplace) to negotiate for favorable ___ or better ___
buying rates coverage
Some plans also include a(n) ___ provision, whereby any part of the deductible that occurs during the final three months of the year (October, November, and December) can be applied to the current year's deductible and can also be applied to the following calendar year's deductible.
carryover
cafeteria plan: employer specifies a set dollar amount that it will provide, and employees choose a ___ from these benefits, depending on their preferences and circumstances. If, after choosing your benefits from the menu offered, you decide you want or need ___ insurance benefits, most employers will deduct the additional cost of providing them from your ___.
combination additional paycheck
A provision often included in health insurance policies to prevent the insured from collecting more than 100 percent of covered charges; it requires that benefit payments be coordinated if the insured is eligible for benefits under more than one policy.
coordination of benefits
The initial amount not covered by an insurance policy and thus the insured's responsibility; it's usually determined on a calendar-year basis or on a per-illness or per-accident basis.
deductible
amount owed by insured before benefits commence
deductible
Part D donut hole: have to reach your ___ which you pay in full, then you reach your ___ which you pay ___% and medicare pays ___%. Then you reach the ___ in which you pay 50%. After this you reach the ___ in which you pay 5%
deductible co-insurance, 25, 75 donut hole catastrophic coverage period
With a managed care plan, the insured pays no ___ and only a small fee, or ___, for office visits and medications. Most medical services—including preventive and routine care that indemnity plans may not cover—are ___ covered when obtained from plan providers
deductibles co-payment fully
Four provisions govern how much your health insurance plan will pay:
deductibles, the participation (co-insurance) clause, the policy's internal limits, and the coordination of benefits clause
Managed care plan members receive comprehensive health care services from a(n) ___ group of doctors, hospitals, and other providers who must meet the managed care provider's specific___.
designated selection standards
Insurance that provides families with weekly or monthly payments to replace income when the insured is unable to work because of a covered illness, injury, or disease.
disability income insurance
HRA: -___ contributes money into account -___ pay the premium and have ___ deductible -usually ___ premiums than traditional group plans -use HRA funds ___ if you have a claim, then pay deductible ___. -what happens to unused funds? -if you leave the job who keeps the money? -tax free income?
employer you, high lower first, out of pocket (OOP) roll over to the next year employer yes
Co-insurance helps reduce the possibility that policyholders will ___ illness and discourages them from incurring ___ medical expenses. Many major medical plans also have a(n) ___ provision that places a cap on the amount of participation required.
fake unnecessary stop-loss
Most individual disability income policies pay a(n) ___ monthly benefit, which is stated in the policy, whereas group plans pay a(n) ___ of gross income
flat fixed percentage
Employee pre-tax contributions to an account that must be spent on qualified medical (or dependent care) expenses.
flexible spending account (FSA)
Some employers offer employees a(n) ___ plan (both names) offering a choice of fringe benefits. Typically, the menu of benefits includes more than one health insurance option, as well as life insurance, disability income insurance, and other benefits
flexible-benefit ("cafeteria") plan
Part A: -___ for those who qualify -covers hospital ___ and ___, other ___ and ___ care -___ apply, benefits vary according to ___ of stay
free room, board, inpatient, outpatient deductibles length
COBRA regulations: You'll be responsible for paying the ___ cost of the insurance if you decide to continue your coverage during this time, but you'll still pay group insurance rates that are often ___ expensive than buying individual insurance. However, you must arrange to continue your coverage ___ leaving your former employer.
full less before
Although Medicare pays for many health care expenses for the disabled and those over 65, there are still ___ in its coverage. Many Medicare enrollees buy ___ policies to fill in these
gaps private insurance
insurance is usually more beneficial for ___ losses
greater
There are two main types of HMOs: ___ and ___
group individual practice associations
An HMO that provides health care services from a central facility; most prevalent in larger cities.
group HMO
Health insurance consisting of contracts written between certain people (employer, union, etc.) and the health care provider.
group insurance
ensures that you can renew the policy until you reach the age stated in the clause, usually age 65. Premiums can be raised over time if justified by the loss experience of all those in the same class
guaranteed renewability
An organization of hospitals, physicians, and other health care providers that have joined to provide comprehensive health care services to its members, who pay a monthly fee.
health maintenance organization (HMO)
managed care plans include ___, ___, and similar plans
health maintenance organizations (HMOs), preferred provider organizations (PPOs)
An account into which employers place contributions that employees can use to pay for medical expenses. Usually combined with a high-deductible health insurance policy.
health reimbursement account (HRA)
A tax-free savings account—funded by employees, employer, or both—to spend on routine medical costs. Usually combined with a high deductible policy to pay for catastrophic care.
health savings account (HSA)
Plans that are better for people who have little need for insurance. Offer low monthly premiums
high deductible plans
health insurance premiums have ___ much more than worker's earnings and inflation. As a result, a larger portion of budgets must go to ___ (___% right now)
increased health care, 28
Health insurance policies are not contracts of indemnity. This means that the insured party can collect multiple payments for the same illness or accident unless health insurance policies include a(n) ___ provision
indemnity coordination of benefits
PPO: -what you pay out of network is more like a(n) ___ plan: -___ for each service -___ and ___ -usually ___ costs -___ need PCP or referral for specialist***
indemnity copay deductible, coinsurance higher don't
POS: Payment for nonaffiliated physician services is similar to ___ plan payments: the plan pays a specified ___ of the cost after your medical costs reach an annual deductible.
indemnity percentage
A health insurance plan in which the health care provider is separate from the insurer, who pays the provider or reimburses you for a specified percentage of expenses after a deductible amount has been met.
indemnity/fee-for-service plan
People who don't work for an employer who provides health insurance—as well as those who require additional personal or family health insurance—can purchase health coverage on a(n) ___ basis directly from providers.
individual
medicaid and the ACA: -enforced a(n) ___ penalty if people didn't have insurance by 2014: -greater of $625 (single) or ___% of income to $2095 (family) or ___% of income ( ___ with cost of living) -allowed ___ gap in coverage before the penalty -other exemptions for ___ hardship and ___ exemption
individual mandate 1, 2.5, increases 3 month financial, religious
A form of HMO in which subscribers receive services from physicians practicing from their own offices and from community hospitals affiliated with this
individual practice association
Which type of HMO is more popular?
individual practice association
managed care plan: ___ provider contracts with ___ provider to offer lower cost insurance. benefits usually only apply to healthcare providers that are ___
insurance healthcare in network
Blue Cross serves as the ___ between the groups that want the services and the physicians who contractually agree to provide them
intermediary
A feature commonly found in health insurance policies that limits the amounts that will be paid for certain specified expenses, even if the claim does not exceed overall policy limits.
internal limits
A health care plan in which subscribers/users contract with the provider organization, which uses a designated group of providers meeting specific selection standards to furnish health care services for a monthly fee
managed care plan
Today, employers are moving away from traditional indemnity plans and adopting ___ plans
managed care plans
medicaid expansion and the ACA: -public exchanges: -"___" for public insurance is required -increases ___ -distribute ___ -___ insurance providers have created their own marketplaces, but they aren't required to do so
marketplace transparency subsidies private
A state-run public assistance program that provides health insurance benefits only to those who are unable to pay for health care.
medicaid
A health insurance plan administered by the federal government to help persons age 65 and over, and others receiving monthly Social Security disability benefits, to meet their health care costs.
medicare
Because of this stable premium guarantee, noncancelable policies generally are ___ expensive than those with only a guaranteed renewability provision
more
PPO: -pay __ out of network -what you pay in network: -___ fee -___ w/ each service -usually no ___ and ___ -___ need PCP or referral for specialist*** -___ usually require a referral anyway
more monthly co-pay deductible, claim filing don't specialist
Today, the differences between group and individual coverage have ___, and many of the advantages of group coverage have ___. As a result, you may want to ___ group and individual policies before deciding which coverage to buy.
narrowed disappeared compare
Does the FSA balance roll over?
no
medicaid expansion and the ACA: -covered preexisting conditions: -can you rate people on prior health? -no lifetime ___ on coverage -what's happening to premiums because of this?
no cap they're increasing
Traditional indemnity plan: -Is there a network? -Process: -pay for ___ -file claim with ___ -get ___/___ pays doctor directly -based on ___ charges -"___" insurance -typically include ___ and ___ -the lower the deductible, the ___ the premium
no services insurance provider reimbursed, IP usual, customary, and reasonable (UCR) old school deductible, 80/20 participation higher
Part B: -___ coverage available for a(n) ___ if eligible for part A -covers doctors, ___, ___ tests, x-rays, and other services including some ___health care -Avg monthly insurance premium ___ with income -Anyone age ___ or over can enroll in SMI.
optional, premium surgeons, lab, home increases 65
medicaid expansion and the ACA: -expansion of public programs: -is true under ___ ACA and the supreme court ___ it. -it's ___ for states to expand coverage -has georgia expanded medicaid?
original, overruled optional no
Disability policies vary in the standards you must meet to receive benefits. Some pay benefits if you're unable to perform the duties of your customary occupation—the ___ definition—whereas others pay only if you can engage in no gainful employment at all—the ___ definition
own occupation any occupation
Part D: -if eligible for ___, you can get this -pay monthly ___ and yearly ___ -___ varies -has coverage gap called the ___
part A premium, deductible coverage donut hole
What's attractive about Plan C? -___ and ___ coverage -supplemental benefits: ___, hearing, ___, check ups, ___ programs
part A, part B vision, dental, wellness
A provision in many health insurance policies stipulating that the insurer will pay some portion—say, 80 or 90 percent—of the amount of the covered loss in excess of the deductible.
participation (coinsurance)
determines how much of covered losses in excess of the deductible that an insurance provider (IP) will pay (2 names)
participation (coinsurance)
A hybrid form of HMO that allows members to go outside the HMO network for care and reimburses them at a specified percentage of the cost.
point-of-service plan (POS)
A health provider that combines the characteristics of the IPA form of HMO with an indemnity plan to provide comprehensive health care services to its subscribers within a network of physicians and hospitals.
preferred provider plan (PPO)
Individual disability policies may contain a(n) ___ clause that supersedes the previously discussed definition of disability when certain types of losses occur. Loss of both hands, sight in both eyes, and hearing in both ears are examples where the insured may be presumed totally disabled and may receive full benefits even though he or she still can be employed in some capacity.
presumptive disability
HMO process: - must choose ___ -___ pays physician -___ refers you for all specialized care*** -___ and ___ must be in network -you pay ___ if you leave network
primary care physician (PCP) Insurance provider PCP PCPs, specialists everything
Health insurance coverage is available from two main sources: ___ and ___ programs.
private government-sponsored
Plan C: -administered by ___ -pay part B premium to ___ and plan C premium to ___ -many IP don't charge premium above ___ premium
private insurer medicare, IP part B
Both group and individual disability income policies are likely to include a(n) ___, usually 7 to 30 days, which is a time delay from the date the policy is issued until benefit privileges are available. Any disability stemming from an illness, injury, or disease that occurs during the this ___ covered—even if it continues beyond this period. This feature keeps costs ___.
probationary period is not down
With a(n) ___ option, you would be paid partial benefits if you can only work part-time or at a lower salary. The "Any Occ" definition is considerably ___ expensive because it gives the insurer more leeway in determining whether the insured should receive benefits.
residual benefit less
Medicare: -administered by ___ -qualified people: -age ___and older and those receiving ___ benefits -funded by ___ taxes paid by ___, ___, and the ___
social security administration 65, social security disability payroll employer, employee, self-employed
Medicaid: -primarily ___ funded -state sets ___ requirements -Health insurance for those who are ___ for medicare and can't ___ private insurance -___ under Affordable Care Act of 2010 (ACA)
state eligibility ineligible, afford expanded
What does coinsurance also include that prevents the insured from paying any charges past a certain amount
stop loss
Because Blue Cross/Blue Shield is a producer cooperative, payments for health care services are seldom made to the ___ but rather directly to the participating hospital or physician.
subscriber
estimating disability insurance needs: 1- calculate ___ pay 2- estimate the ___ amounts of ___ benefits from government or employer programs. 3- add up your ___ monthly disability benefits. 4- Subtract your existing monthly ___ from your current monthly ___.
take home monthly, disability existing disability benefits, take-home pay
Employers bear nearly ___ cost of workers' compensation insurance in most states. Premiums are based on ___ usage; employers who file the most claims pay the ___ rates.___ people are required to contribute to workers' compensation for themselves and their employees.
the entire historical highest self-employed
If your doctor charges more than the UCR, you may be responsible for ___ amount of the excess. It should be noted that there are ___ indemnity plans left in the United States.
the full very few
Most private health insurance plans fall into one of two categories: ___ and ___
traditional indemnity (fee-for-service) plans, managed care plans
period between disability onset and when insurance funds are releasesd. Can last from 30 days to a year. Must cover this period with your own ___ funds.
waiting period emergency
Health insurance required by state and federal governments and paid nearly in full by employers in most states; it compensates workers for job-related illness or injury.
worker's compensation insurance
usually private insurance will have coordination of benefits with clause with ___
workers compensation
HSA: -___, ___ or ___ contribute money to the account -___ pay premium, have ___ deductible -usually ___ premium than traditional group plans -use HSA funds ___ if you have a claim, then pay deductible ___ -what happens to unused funds? -if you leave the job who keeps the money? -tax free income?
your employer, you, both you, high lower first, OOP roll over to the next year you keep money yes
