Health Insurance Exam Study Guide

Vocabulary-style flashcards covering the core concepts of health insurance, including risk types, plan structures, disability, Medicare, Medicaid, and legal/tax regulations.

Risk

Chance of loss.

Peril

Cause of loss.

Hazard

Condition increasing loss.

Pure Risk

Insurable risk only.

Speculative Risk

Risk involving gain or loss; not insurable.

Law of Large Numbers

Principle stating a larger group leads to more predictable losses.

Indemnity

To restore an individual to the financial position they were in before a loss.

HMO

Health plan featuring lower costs, a required PCP, and required referrals.

PPO

Health plan offering more provider freedom.

POS

A mix of HMO and PPO plans.

EPO

A network-only health plan.

Comprehensive Policy

One policy that covers major health needs.

Supplemental Policy

An extra policy used to cover gaps in coverage.

Hospital Indemnity

Policy that pays by days spent in the hospital rather than by expenses incurred.

Critical Illness

Policy providing a lump sum cash benefit upon diagnosis.

Specified Disease

Policy that covers a named illness only.

Dental Scheduled

Dental plan with a fixed benefit schedule.

Dental UCR

Dental plan based on usual, customary, and reasonable charges.

COBRA

Continuation coverage lasting $18$ or $36$ months.

COBRA Election

The period of $60$ days allowed to choose continuation coverage.

COBRA Premium

Up to $102\%$ of the premium cost.

HIPAA

Includes a $63$-day rule for creditable coverage.

HIPAA Employer Rule

Applies to employers with $20+$ employees.

ACA Essential Benefits

The $10$ mandatory health benefits required by the Affordable Care Act.

ACA Dependent Coverage

Children remain covered until age $26$.

Bronze Tier

ACA metal tier with a $60/40$ split.

Silver Tier

ACA metal tier with a $70/30$ split.

Gold Tier

ACA metal tier with an $80/20$ split.

Platinum Tier

ACA metal tier with a $90/10$ split.

Community Rating

Practice of charging the same rate for an area with no medical underwriting.

Own Occupation

Disability definition where the insured cannot do their own job.

Any Occupation

Disability definition where the insured cannot do any job.

Elimination Period

The waiting period before benefits begin.

Probationary Period

A waiting period specifically for sickness.

Presumptive Disability

Condition where disability is assumed, such as blindness, hearing loss, speech loss, or loss of limbs.

Residual Disability

Benefit based on an income-loss percentage.

Flat Disability

A benefit paid as a flat $\text{\%}$.

Waiver of Premium

Policy feature where premiums are waived during a period of disability.

COLA Rider

Rider that causes benefits to increase with inflation.

Business Overhead

Insurance that pays business expenses but does not cover the owner.

Key Person

Protects a business from the loss of an important employee.

Medicare Part A

Covers hospital stays.

Medicare Part B

Covers medical and doctor visits.

Medicare Part C

Medicare Advantage plan.

Medicare Part D

Covers prescription drugs.

Part D Penalty

A $1\%$ monthly penalty for late enrollment.

Medigap Open Enrollment

Lasts $6$ months starting from enrollment in Medicare Part B.

Medicare Select

A network-based Medigap policy.

Medicaid

State/federal health assistance for low-income individuals.

LTC Trigger

Requirement to need help with $2$ of $6$ ADLs.

Skilled Care

Medical or $24$-hour care.

Custodial Care

Care for daily living needs.

LTC Preexisting

A $6$-month exclusion period for pre-existing conditions.

Workers Compensation

Covers job-related injuries only.

Contributory Plan

Requires $75\%$ participation.

Noncontributory Plan

Requires $100\%$ participation.

Conversion Privilege

The right to convert coverage within $31$ days without proof of insurability.

Waiting Period

Exclusion period for pre-existing conditions.

Group Underwriting

Evaluation based on the group's reason for existence, stability, and persistency.

PCP

Primary Care Physician.

Gatekeeper

Provider who controls patient referrals.

Capitation

System where a provider is paid a fixed amount.

Managed Care

Cost-control healthcare systems.

Staff Model HMO

HMO where doctors are employees.

Network Model HMO

HMO utilizing a provider network.

IPA

Independent Practice Association.

Employer Disability Premiums

Lead to taxable benefits for the employee.

Personal Disability Premiums

Lead to tax-free benefits.

7.5% AGI Rule

The threshold for medical expense deductions.

Self-employed Medical

Premiums are $100\%$ deductible.

HSA

Health Savings Account requiring an HDHP.

HSA Penalty

A $20\%$ penalty for nonqualified withdrawals.

Notice of Claim

Must be provided within $20$ days.

Claim Forms

Must be provided within $15$ days.

Proof of Loss

Must be submitted within $90$ days.

Legal Action Timelines

A waiting period of $60$ days is required, with up to $3$ years to sue.

Grace Period (Weekly)

$7$ days.

Grace Period (Monthly)

$10$ days.

Grace Period (Quarterly+)

$31$ days.

Free Look Period

$10$ days standard, or $30$ days for seniors.

Policy Approval

Duration of $90$ days.