types of health policies

child and dependent care expenses must be for teh care of one or more qualifying persons

A dependent who was under age 13 when the care was provided and who can be claimed as an exemption on teh emplyees federal income tax return a spouse who was physically or mentally not able to care for himself a dependent who was phyically or mentally not able to care for himself and who can be claimes as an exemption

Accidental bodily injury

An unforeseen and unintended injury that resulted form an accident rather than a sickness

FSA

Exempt from federal income taxes, social security taxes and in most cases, state income taxes, saving 1/3 or more in taxes.

General CHaracteristics

HMO provides benefits in teh form of services. provides both teh financing and patient care for its members

Prepaid Basis

HMO receives a flat amount each month attributed to each member, whether they see a physician or not.

comprehensive coverage

Health insurance that provides coverage for most types of medical expenses

three basic coverages

Hospital, surgical, and medical may be puchased separatetely or tagether as a package.

preventive care services

Main goal fo teh HMO act was to reduce teh cost of health care.

statistics

a 30 percent chance of a 25 year old being disabled for more than 90 days prior to age 65. it is far less likely that the same 25 year old will suffer a premature death prior to age 65.

PPO

a group of physicains and hospitals that contract with emplyers, insurer, or third party organizations to provide medical care services at a reduced fee. tjeu do not provide care on a prepaid basis are paid a fee for service. subscibers are not required to use physicians or facilities that hae contracts with the PPO

Lump Sum

a payout method that pays the beneficiary the entire benefit in one payment

capital sum

a percentage of that principal sum

Copayments

a specific part of teh cost of care or a flat dollar amount that must be paid by teh member

Deductible

a specified dollar amount that the insured must pay first before the insurance company will pay the policy benefits

Elimination period

a waiting period that is imposed on teh insured from the onset of disability until benefit payments commence. puropse is to eliminate coverage for short-tem disabilites range rom 30 to 180 days. a longer elimination period is lower premium will be eligibl eth enext day payments will not begin for 30 days.

Probationary period

about 10 to 30 days. only for sickness

riders

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

sickness

an illness, which first manifests itself while the policy is in force

,,,

any physician or hospital that qualifies and agrees to follow the PPo's standards and charge the appropriate fees that teh PPo has established can be added to teh PPO's approved list at any time physicians may belong to several PPO groups

Healthy savings accounts

are designed to help individuals save for qualified health expenses that they their spouse or their dependents incur

HSA

are linked to high deductible insurance each year individuals are allowed to save up to cetain limits . when opening an account an individual must be under the age of medicare eligibiliy.

Social insurance supplement or social security Riders

are used to supplement or replace benefits that might be payable under SS disability. when the insured is eligible for SS benefits but before teh benefits begin if teh insured has been denied coverage under social security when the amount payable under SS is less than the amount payable under the rider

Benifit limitations

based on a percentage of the insured past earnings. the maximum benefits the insurer is willing to accept for an individual risk.

three types of policys used for business

business overhead expence, Key person disability and disability buy sell insurance

Accidental death amd dismemberment

can be written as a rider or as a separate policy. usually a group life and group health plans. it provides for the payment of a lump sum benefit, in teh even tthat teh insured dies from accident. or if they lose a body part

prohibited actions

cancel, nonrenew or otherwise terminate a LTC policy on teh groundds of the insured's age or the deterioration of mental or physical condition establish a new waiting period when coverage is converted or replaced withing the same company, except for increased benefits voluntarily selected by the insured or cover only skilled nursing care or provide significantly more coverage for skilled care than lower levels of care

Primary care physician vs referral physician

care is provided to members of the HMO by a limited number of physicians that are approved to practice in teh HMO

Point-of-Service

combination of HMO and PPO

Basic surgical expence coverage

common with hospital expence policies. coverage is surgeons fees, anesthesiologist and the operating room when it is not covered as a miscellaneous medical item.

Sickness

contracted after the policy ahs been in force at least 30 days.

preferred provider organizations

could be a traditional medical systems answer to HMOs. in this system the physicains are paid fees for their services rather than a salary. members can utilize any physician they choose.

special risk policy

cover unusual types of risks that are not normally covered under AD&D policies.

Long term care policies

coverage for individuals who are no longer able to live an independent lifestype and require living assistance at home or in a nursing home can vary in the number of days, home visits, the amount paid for nursing home care, and other contract provisions. provide coverage for atleast 12 months

skilled care

daily nursing and rehabilitative care under direction of physician. almost always provided in an institutional setting. care that can be given by nonprofessional staff is not considered skilled caer

limited risk policies

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

Group disability policy

differences between group and individual

Relative value

each surgical procedure will be assigned a number of points that are relative to the number o fpoints assigned to the maximum benefit. usually assigned to major surgical procedures, . the assigned points are multiplied by a conversion factor. this factor represents the total amount payable per point.

usually inclde

elimination period which is usually 30 days or more the insured must be confined in a nursing home before benefits begin.

Health Maintenance Organizations

forced employers with more than 25 employees to offer the HMO as an alternative to their regular health plans

Flexible Spending Accounts

form of cafeteria plan benefit funded by salary reduction and employer contributions. emplyees deposit an amount of their paycheck into an account before paying income taxes. subject to annual maximum and use or lose rule

Business disability buyout policy

generally have an extremely long elimination period, possibly one or two years. generally also provide a lafge lump-sum benefit to buy out the business

dependent care account

help pay for dependents care expenses which makes it possible for an employee and his or her spouse to continue to work

Baic hospital expense coverage

hospital expence policeis cover hospital room and board and miscllaneous hospital expenses, such as lab and X-ray charges, medicines, use of operating room and supplies, there is no deductible and the limits on room and board are set at a specified dollar amount per day up to teh maximum number of days.

Benefit period

how long coverages applies after the elimination period. usually 2-5 years. the longer the period the higher the premium

indemnity plan features

if a non-member physician is utilized under the POINT OF SERVICE plan, then the attending physician will be paid a fee for service, but the member patient will have a pay a higher coinsurance amount or percentage for the privilge

Limited service area

if individuals live within the boundaries, they are eligible to belong to the HO, but if they do not live within the boundaries they are ineligible

HSA holder

if someone uses the money other than for health they pay taxes on it plus a 20% penalty. after 65 a withdrawal used for a nonhealth porpuse will be taxed but not penalized

Home convalescent care

in home under a planned program established by physician

Referral physician

in order for the member to get to see a specialist, teh primary care physician must refer teh member. in many Hmo's there is a financial cost to the primary care physicain for referring a patient. HMOs must have mechanisms to handle complaints which sometimes result in a delay or referral or complaints about other patient care or coverage concerns

Disability Income insurance

is designed to replace lost incom ein the event of this contingencu amd os a vita component of a comprehensive insurance program. it may be purchased individually or through an emplyer on a group basis

prinicipal sum

is paid for accidental death in case of loss of sight or accidental dismemberment

corridor deductible

it applied between teh basic coverage and the major medical coverage

Limited choice of providers

limit cost by only providing care from physicians that meet their standards and are willing to provide care at a prenegotiated price

IRS

limits the annual contribution for dependent care accounts to a specified amount thta gets adjusted annually for cost of living even if both parents have acces to flexible care accounts their combined contributions cannot exceed the amount

qualified life event changes

marital status number of dependents one fo dependents becoe eligible for or no longer satisfies the coverage requirements under the Medical reimbyyrsemebt okab for unmarried dependents due to attained age, student status, or any similar circumstances the insured or spouss or dependednt employent status taht affects eligibility under teh plan changes in dependent care provider family medical leave

specocoa; scjedi;es

may express the amount payable as a percentage of a maximum benefit, list a specified amount, or assign a relative value that when multiplied by its conversion factor gives teh benefit payable

long term care

may provide coverage for home health care adult care hospice care or respite car

eligible

must be covered by a high deductible health plan must not be covered by other health insuracne must not be eligible for medicare and cant be claimed dependent on someone else's tax retun

general

no changes can be made during the plan year

Miscellaneous hospital expenses

normally have a separate limit. the policy may specify a maximum limit for certain types of expenses. the miscellaneous expence limits may not pay the full amount needed by teh insured in teh event of a lengthy hospital stay

Tax emempt

not subject to taxation

intermediate care

occational nursing or rehab care for stable conditions require daily medical assistance on aless frequent basis ordered by a physician maybe be in a nursing home intermediate care unit or patients home

Major medical policeis

offer a broad range of coverage. comprehensive coverage for hospital expenses catastrophic medical expence protection benefits for prolonged injury or illness

HMOs

offer free annual check-ups for the entire family. the HMOs hope to catch diseases in teh earliest stages. offer free or low-cost immunizations ot members in an effort to prevent cetain diseases.

High Dectible heath plans

often used in coordination with MSA, HSAs, or HRAs. the high dedcutibel health plan features higher annual deductibles and out of pocket limits than tradiion health plans which means lower premiums. tehy credit a portion of the health plan premium into the coordinatin gMSA, HSA, or HRA on a monthly basis

ect

only pays for accidental losses and is thus considered a pure form of accident insurance

not care for themselves

person who cannot dress clean or feed themselves have constant attention to prevent tehm form injuring themselves or others

custodial care

personal needs such as assistance in eating dressing or bathing can be provided by nonmedical personnel can be in an institutional setting or the patients home

group disability

plans also have a minimum participation requirements. usually the emplyee must have worked for 30 to 90 days before becomin geligible for coverage

exclusions

pre-existing conditions mental and nervous disorders or disease alcoholism and drug addiction caused by war payable by government, medicare, workers comp or similar coverage

group long term plans

provide maximum benefit period of more than 2 years, with monthly benefits usually limited to 60 percent of the individuals income

Bsic medical expense coverage( basic physician's nonsurgical expence coverage'

provides coverage for nonsurgical services a physician provides. there is no deductible with benefits, but coverage is usually limited to number of visits per day, limit per visit, or limit per hospital stay. . these policies usually offer only limited benefits that are subject to time limitations. the insured is often required to pay a considerable sume of money in addition to the benefits paid by the medical expence policies.

....

rarely will an insurer write a disability income policy that will reimburse the individual for 100% of lost income. so the insured will not be able to profit from disability

Underwriting

risk selection and classification process

Home health care

skilled nurses or other professional services occasional visits

Business overhead expence

sold to small business owners who must continue to meet overhead expenses, rent, utilityes, salaries, installment purchases, leased equipment. usually an elimination period of 15 to 30 days and benefit payments are usually limited to one or two years. are tax deductibel to the business as a business expence

Presumptive disability

specifies the conditions that will automatically qualify the insured for full disability benefits. provides benefit for dismemberment. total and peranent blindness, or loss of speech or hearing. some policies require actual severance of limbs rather tahn loss of us

Disability buyout agreement

specifies who will purchase a disabled parners interest and legally obligates that person or party to purchase such interest upon disability. with disability buy-sell insurance, teh premiums paid by the business are not tax deductibel and the benfits are received tax-free.

Taxable

subject to taxation

Cancellation

termination of an in-force insurance policy, by either the insured or the insurer, prior to the expiration date shown in the policy

Nonrenewal

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

Surgical schedule

that lists the types of operations covered and their assigned dollar amounts.

Key employee policy

the contract is owned by teh business the premium is paid by the business and the business it the beneficiary. must have the consent of the key person

Injury

the damage to the body is unexpected and unintednede. provide broader coverage than a policy that uses teh accidental means definition

plan

the emplyees do not have to be locked into one plan or make a choice between teh two plans.

POS

the individuals can visit an in-network provider at their discretion. participans usually have access to a provider network that is controlled by a primary care physician. also refered to as OPEN ENDED HMO's

PPO

the insured does not have to select a primary care physician. may choose medical providers not found on teh preferred list receive care from any provider if a non-network provider is used the out of pocket costs will be higher. all network providers are considered PREFERRED some services may require plan pre-certificaion, an evaluation of teh medical necessity of inpatient admissions and the number of days required to treat your condition

Benefit period

the length of time over which the monthly disability benefit payments will last for each disability after teh elimination period most periods are 1,2, 5 years and to age 65. the longer teh benefit period the higher the premium will be

Hospital Services/ Emergency care

the services may be limited for treatment of mental, emotional or nervous disorders, including alcohol or drug rehabilitation or treatment

Medical Expence insurance

they provide benefits for the cost of medical care that results form accidents or sickness.

Cafeteria plan

type of employee benefit plan that allows insureds to choose between difference types of benefits

short term group plans

unsually provide maximum benefit periods of 10-26 weeks, with weekly benefits of 50% to 100% of the individuals income. have maximum benefit period of 6 months to 2 years

Supplemental major medical policies

used to supplemetn the coverage payable under a basic medical expence policy. the basic expense policy will provide coverage on a first-dollar basis. after the limits are doen teh insured must pay a corridor deductibel

First dollar coverage

usually do not require the insured to pay a deductibel. however the basic medical coverages usually have more limited coverage than the major medical policies

group plans

usually make benefits supplemental to any benefits received uner workers compensation some group disability plans limit coverage to only nonoccupational disabilities

policy

usually pay the full principal for the loss of sight in both eyes, or two or more limbs. it may only pay 50% for the loss of one hand or one foot. as long as the death is caused by accident and occurs within 90 days

group plans

usually specity the benefits benefits based on a percentage of the workers incom ewhile individual polies usually specity a flat amount

primary care physician

when an individual becomes a member of the HMO they will choose their primary care physician or gatekeeper. onece chosen the physician will be regularly compensated for being responsible for teh care of that member. whether or not the care is provided.