[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
