CH 9 Medical Expense Insurance
Call Kai
Learn
Practice Test
Spaced Repetition
Match
Flashcards
Knowt Play1/81
There's no tags or description
Looks like no tags are added yet.
Name | Mastery | Learn | Test | Matching | Spaced | Call with Kai | Chat |
|---|
No analytics yet
Send a link to your students to track their progress
82 Terms
What are medical expense insurance plans designed to cover?
Costs of medical care resulting from accidents or sickness.
What are the three basic types of medical expense coverage?
Hospital expense, surgical expense, and medical expense coverage.
What is first-dollar coverage?
Coverage where benefits begin with the first dollar of expense and usually does not require a deductible.
What is an indemnity plan?
A plan that pays benefits based on a predetermined fixed amount regardless of the actual expense incurred.
What does basic hospital expense coverage pay for?
Hospital room and board, lab tests, X-rays, medicines, operating room use, and supplies.
Does basic hospital expense coverage have a deductible?
No
How are hospital room and board benefits usually limited?
By a specified dollar amount per day and a maximum number of days.
What is basic medical expense coverage also called?
Basic physician's nonsurgical expense coverage.
What does basic medical expense coverage pay for?
Nonsurgical physician services, usually while confined in a hospital.
Does basic medical expense coverage have deductibles?
No, but benefits are limited.
What does basic surgical expense coverage pay for?
Surgeons' fees, anesthesiologist fees, and operating room expenses.
How are surgical benefits determined?
Through a surgical schedule listing procedures and assigned dollar amounts.
What is comprehensive major medical insurance?
A combination of basic expense coverage and major medical coverage in one policy.
What expenses does comprehensive major medical cover?
Hospital, physician, surgical, nursing, drugs, lab tests, and other medical expenses.
What features are included in major medical plans?
Deductibles and coinsurance.
What is supplemental major medical insurance?
Coverage that pays expenses not covered by basic medical policies or expenses exceeding basic policy limits.
What does HMO stand for?
Health Maintenance Organization.
How does an HMO provide benefits?
Through services rather than reimbursement.
What is the main goal of an HMO?
Preventive care and controlling healthcare costs.
How do HMOs operate financially?
On a prepaid, capitated basis.
What is capitation?
A fixed payment made to physicians per enrolled member regardless of whether care is provided.
Are HMOs usually subject to deductibles?
No
What is an open panel HMO?
Providers can treat both HMO members and nonmembers.
What does PPO stand for?
Preferred Provider Organization.
What happens when PPO members use out-of-network providers?
They pay higher out-of-pocket costs.
What does POS stand for?
Point-of-Service plan.
What type of plan is POS?
A combination of HMO and PPO.
How does POS work?
Members can use network providers or go outside the network for higher costs.
What is another name for POS plans?
Open-ended HMOs.
What is an EPO? (Exclusive Provider Organization)
A plan requiring members to use specific preferred providers.
Why do self-insured plans buy stop-loss insurance?
To protect against extremely large losses.
What is an MSA?
Medical Savings Account.
Who funds an MSA?
Employer.
What type of plan is linked to an MSA?
High deductible health plan.
Who can have an MSA?
Small employers (50 or fewer employees) or self-employed individuals.
What happens to unused MSA funds?
They may remain and earn interest or be withdrawn as taxable income
What penalty applies to nonqualified MSA withdrawals?
Income tax plus 20% additional tax.
What is an FSA?
Flexible Spending Account.
How are FSAs funded?
Employee salary reductions and employer contributions.
What is the FSA "use-or-lose" rule?
Unused funds generally do not carry over after the plan year.
Are FSA contributions taxable?
No, they are generally exempt from federal income and FICA taxes.
What is an HRA?
Health Reimbursement Account.
Who funds an HRA?
Employer only.
Can HRA funds roll over?
Yes, if the employer allows it.
What is an HSA?
Health Savings Account.
What must someone have to qualify for an HSA?
High deductible health plan
No other health coverage
Not eligible for Medicare
Not claimed as another person's dependent
Who owns an HSA?
The individual.
Are HSAs portable?
Yes, they follow the employee.
Does an HRA follow an employee to a new job?
No
What penalty applies to nonmedical HSA withdrawals before age 65?
Tax plus 20% penalty.
What happens to nonmedical HSA withdrawals after age 65?
Taxed but no penalty.
Is pediatric dental coverage required under ACA?
Yes, for children age 18 and younger.
Is pediatric vision coverage required under ACA?
Yes
What does AD&D stand for?
Accidental Death and Dismemberment.
What is the principal sum in AD&D?
The full face amount paid for accidental death.
What is the capital sum in AD&D?
A percentage of the face amount paid for dismemberment.
What is an elimination period?
Waiting period before disability benefits begin.
Minimum health policy grace periods?
Weekly premium: 7 days
Monthly premium: 10 days
Other modes: 31 days
What are the two main types of eligible groups?
Employer groups
Association groups
How many members must an association group have?
At least 100 members.
What is the purpose of COB?
Prevent duplicate payments and overinsurance.
What is the birthday rule?
Parent whose birthday occurs earlier in the year has primary coverage.
What is a blanket policy?
Covers members of a group participating in a specific activity without naming individuals.
Who regulates HMOs in California?
Department of Managed Health Care (DMHC).
Who regulates most PPO/EPO plans?
California Department of Insurance (CDI).
What does COBRA do?
Allows continuation of group health coverage after qualifying events.
Employers subject to federal COBRA?
Employers with 20+ employees.
COBRA continuation period after termination/reduction of hours?
18 months
COBRA continuation for death/divorce/legal separation?
36 months
COBRA premium can be charged up to what amount?
102% of premium.
How much leave does FMLA provide?
12 workweeks in a 12-month period.
What does HIPAA protect against?
Discrimination based on health factors and protects portability of coverage.
What age can children remain on parents' health plans?
Age 26
What are the only factors insurers may use for ACA premium rates?
Geographic area
Family composition
Age
Tobacco use
Bronze/Silver/Gold/Platinum plan coverage levels?
60%/70%/80%/90%
What are the 10 essential health benefits?
Ambulatory patient services
Emergency services
Hospitalization
Pregnancy/maternity/newborn care
Mental health/substance abuse
Prescription drugs
Rehabilitative/habilitative services
Laboratory services
Preventive/wellness/chronic disease management
Pediatric services including dental and vision
What percentage of premiums must insurers spend on medical care?
Individual/small group: 80%
Large group: 85%
How long do individuals have to enroll after qualifying events?
60 days.
When is annual ACA open enrollment generally?
November 1–January 15.