Mass. Health Insurance Exam Definitions & Terms Study Set

HEALTH INSURANCE COVERED BENEFITS

- Hospital and medical bills

- Loss of income - disability

- Dental bills

- Long-term care

LIMITED BENEFIT POLICIES

- Accident only

- Dread disease

- Critical illness

- Hospital indemnity

- Credit disability

- Blanket coverage

- Prescription drugs

- Vision

- Hearing

HEALTH INSURANCE COMMON EXCLUSIONS

- Intentional

- War

- Elective cosmetic surgery

- Workers compensation

- Felony

AFFORDABLE CARE ACT

- PPACA, Obamacare, Health Care Reform

- Signed in 2010

- Additional in 2014

INDIVIDUAL MANDATE

- Legal residents required to have qualifying health care coverage

- TCJA reduced penalty to 0$/0%

EHB

- Health plans must be qualified to fit ACA standard

- QHP's, Medical state plans, and insurance health exchange must meet requirements

EMERGENCY MEDICAL SERVICES

- No pre-authorization

- In or out of network

- Normal cost-sharing requirements

PROHIBITION ON LIFETIME/ANNUAL LIMIT

- On all EHB's (except for grandfathered)

- Limited allowed on non-EHB's

METAL TIERS

- Platinum = 90%

- Gold = 80%

- Silver = 70%

- Bronze = 60%

- Must cover minimums EHB

PRE-EXISTING CONDITIONS

- Health plans can no longer include pre-existing conditions (except grandfathered)

ELIGABILITY

- Income, Employment, Coverage through employer

GUARANTEED ISSUE

- Must be offered to any individual or employer in state

- Subject to rules

QHP's

- Provide EHB's

- Only available on the exchange

- Only plan that provides tax credits and cost sharing

SHOP

- Online application to compare health plans

- 50 or less full time employees

SUBSIDIES

- Money given by federal government

- Advanced premium tax credits

- Cost-sharing (only silver)

NAVIGATORS

- Funded by government

- CANNOT sell insurance or provide advice

- Help determine eligibility for public assistance

EMPLOYER MANDATE

- 50 or more employees

- Employer shared responsibility

- Penalty if not followed

HEALTH VARE TAX CREDIT FOR SMALL EMPLOYERS

- Maximum credit:

- 50% of premiums paid for small business employers

- 35% of premiums paid for small tax-exempt employers

- Eligible for two years

ENTIRE CONTRACT (AIR) - REQUIRED

- Application of insurance

- Insurance policy

- Riders

TIME LIMIT ON CONSENTING APPLICATION INFO - REQUIRED

- 2 years after application

- Fraud in application can void policy

GRACE PERIOD FOLLOWING DUE DATE OF PREMIUM - REQUIRED

- Insurance still in force

- 7 days if weekly

- 10 days if monthly

- 31 days if above

- Unpaid deducted from claim

RESINSTATEMENT - REQUIRED

- Application & receipt

- Must deny within 45 days after effect

- Accident claims covers immediately

- Sickness covered 10 days after reinstatement (probationary period)

NOTICE OF CLAIM - REQUIRED

- 20 days after loss

- If continuing disability can only be required proof every 6 months

CLAIM FORMS - REQUIRED

- Must be furnished to insured within 15 days of notice of loss

PROOF OF LOSS - REQUIRED

- 90 days

TIME PAYMENT OF CLAIMS - REQUIRED

- Immediately

- At least monthly if disability or long term care

PAYMENT OF CLAIMS - REQUIRED

- Any death benefits: beneficiary or insured estate

- Facility of payments: $1,000 to a family member

MEDICAL EXAMS AND AUTOPSY - REQUIRED

- If company requires and state allows

- Company pays all costs

LEGAL ACTION AGAINST INSURER - REQUIRED

- Earliest 60 days after proof of loss

- Maximum 3 years after proof of loss

CHANGE OF BENEFICIARY - REQUIRED

- Any time by owner

- Permission of beneficiary if irrevocable

CHANGE OF OCCUPATION - OPTIONAL

- More hazard = reduce benefits

- Less hazard = Refund of excess premium

MISSTATEMENT OF AGE - OPTIONAL

- Younger than stated - Benefits increased

- Older than stated - Benefits reduced

OTHER INSURANCE WITH SAME INSURER - OPTIONAL

- Total of all policies exceeds maximums = benefits reduced & excess premiums refunded

INSURANCE WITH OTHER INSURER - OPTIONAL

- Each company pays proportionate share

- Excess premiums refunded

RELATION OF EARNINGS TO INSURANCE - OPTIONAL

- Disability benefit exceeds earnings

- Benefits reduced

- Excess premiums refunded

UNPAID PREMIUM - OPTIONAL

- Can be deducted from claim

CANCELLATION - OPTIONAL

- Company must give 5 day notice

- Unearned premium must be refunded pro rata

- Unsured cancels short rate penalty will apply

CONFORMITY WITH STATE STATUTES - OPTIONAL

- Makes policy comply with laws of the insured state of residence

ILLEGAL OCCUPATION - OPTIONAL

- No benefits = committing a felony or engaged in illegal occupation

ALCOHOL & NARCOTICS - OPTIONAL

- No benefits if loss caused by alcohol or narcotics

FREE LOOK - OTHER

- 10 days from receipt (30 days for Medicare, long term care)

- Begins date received by policy holder

- Complete refund

INSURING CLAUSE - OTHER

- Promise to pay

- Conditions of payment

CONSIDERATION CLAUSE - OTHER

- Company promises to pay

- Applicant provides info and pays premium

RENEWABILITY - OTHER

- Cancelable any time

OPTIONALLY RENEWABLE - OTHER

- Company may not renew; anniversary or premium due date

CONDITIONALLY RENEWABLE - OTHER

- Nonrenewable can occur only under certain conditions such as reaching 65

GUARANTEED RENEWABILITY - OTHER

- Insurer must renew

- Premiums can be raised by CLASSES

NONCANCELABLE - OTHER

- Insurer must renew

- Premiums cannot be raised

MILITARY SUSPENSE - OTHER

- Temporary suspension while in military

- Reactive after leaving military

OWN OCCUPATION - DISABILITY

- Inability to perform any or all duties of insured normal occupation

- More liberal definition for insured

ANY OCCUPATION - DISABILITY

- Any occ. for which insured is qualified by training education and experience

- More difficult to qualify

INCOME REPLACEMENT - DISABILITY

- Reduction in income triggers payment

PRESUMPTIVE DISABILITY

- Auto qualification

- Loss of 2 limbs

- Blindness both eyes

- Loss of speech

- Loss of hearing both ears

MEDICALLY DEFINED - DISABILITY

- House confinement and doctors care

WAIVER OF PREMIUM - DISABILITY

- Waives further premium payments after waiting period

- Refunds premiums paid during waiting period

ADDITIONAL MONTHLY BENEFIT RIDER - DISABILITY

- Pays additional benefit during first 6-12 months

- Pays even if the insured receives gov't benefits

SOCIAL INSURANCE SUPPLEMENT - DISABILITY

- Pays when social benefits are not being paid

- Difference between gov't and amount of rider

- Only during benefit period

PARTIAL DISABILITY

- Returns to work in reduced capacity

- Usually pays 50% of benefit

- No longer than 3-6 months

RESIDUAL DISABILITY

- Paid whether insured is able to work full or part time

- Benefit based on reduction of income

- Pays as long as reduction in income continues

RECURRENT DISABILITY

- Condition recurs after returning to work

- Doesn't have to wait to start receiving benefit

- Conditions must recur within a certain time frame after returning

ACCIDENTAL DEATH AND DISMEMBERMENT

- Amount of rider is the principal sum: Paid if accidental death or loss of sight or 2 limbs

- Smaller benefit for one limb, eye, etc

REHABILITATION BENEFIT

- Total disability

- Helps insured train for a new occupation

- Pays as long as insured is disabled and stays in program

MEDICAL REIMBURSEMENT

- Helps pay medical bills for a non-disabling injustice

RETURN OF PREMIUM

- Refunds stated % of premium after a stated time

- benefits are subtracted

CASH SURRENDER VALUE

- Accumulates cash values that are equal to all premiums paid

- If the policy is surrendered for its cash value, any benefits are subtracted

COMMON EXCLUSIONS IN DISABILITY INCOME

- War

- Suicide

- Non-commercial aviation

- Commission of felony

- Living overseas

DISABILITY UNDERWRITING

- Occupation

- Benefit Limits

- Policy issuance alternatives: Increased premium, exclusion rider

SOCIAL SECURITY DISABILITY

- Must have 6 credits in last 13 quarters

- # of credits required increases with age up to 62

- Fully insured when 40 credits have been earned

- 5 month waiting period for benefits

- Not retroactive to cover first 5 months

- Disability must last 12 months

- Amount of benefit based upon PIA

- Spouse and children may receive benefits

FEE FOR SERVICE

- Provider paid for services; insured's

PREPAID

- Provider is paid a set fee in advance; subscribers

BASIC HOSPITAL, MEDICAL, AND SURGICAL POLCIIES

- Low coverage; no deductibles

MAJOR MEDICAL EXCLUSIONS

- Self-inflicted injuries

- Injury resulting from war

- Illness or injury from military duty

- Air travel (non-commercial)

- Felony

- Experimental

- Workers comp covered care

- Gov't facility

- Elective cosmetic

- Hearing aids

- Custodial care

HMO's

- Managed care

- Prepaid services

- Co-pays

- Gatekeeper

- Limited choice of providers

- Limited service area

PPO

- Managed care

- Fee for service

- Pre-negotiated rates

- Insured pays less in network of PPO providers

POS

- HMO allows subscribers to use providers outside of the HMO

- No gate keeper for out of network services

- Subscribers pay more of the cost

- Called open-ended HMO

COST CONTAINMENT - MANAGED CARE

- Preventative care

- Reducing hospital care costs (Outpaitient benefits; 2nd surgical, preauth, limits on stay)

- Alt. To hospital care (skilled nursing, intermediate, rehab, home health)

- Utilization management (prospective, concurrent, retrospective)

GROUP INSURANCE

- Less expensive than individual

- Sponsored receives master contract; insureds receive certificate

- Experience rating

GROUP TYPES

- Employer sponsored

- MET

- MEWA

- Taft Hartley (Labor union)

- Trade or professional assoc.

- Lender group (ins no greater than debt)

COBRA - CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT

- Applies to employers who regularly employ 20 or more people

- Employers must allow employee or dependents to remain on the group plan

- Applies to medical and dental - not life

- Extends for 18 months if: employment terminated or reduction in hours

- Extends for 36 months if: Divorce, too old, death of employee

- Premium is 102% of regular group premium

- COBRA auto ends if: premium not paid, employer stops group plan, cover by another plan, eligible for Medicare

OBRA

- 29 months if disabled at time of termination

HIPPA

- Pre-existing conditions

- Includes most health coverage

- Guaranteed 48 hour hospital stay for new mothers and 96 for C-section

- Small employers cannot be denied

TYPES OF DENTAL TREATMENT

- Diagnostic and preventative (eye exams; x-rays; cleanings)

- Restorative (repairing damaged teeth)

- Oral surgery (surgery in oral cavity)

- Endodontics (pulp; soft tissue in center of tooth)

- Periodontics (gums)

- Prosthodontics (Artificial replacements; bridges & implants)

- Orthdontics (irregular teeth alignment)

FEATURES OF DENTAL INSURANCE

- Any provider vs. PPO

- Scheduled vs. non-scheduled benefits

- Diagnostic & preventative - 100% covered

- Basic services (fillings, crowns, anasthesia - coins. 80/20 - subject to annual limit)

- Major services (root canals, oral surgery, gum treatments - coins. 50/50

- Predetermination of benefits often required

GROUP DENTAL

- Usually separate policy

- If integrated with medical - one deductible for both

ADVERSE SELECTION- DENTAL

- Probationary periods

- Limitations on benefits for late enrollees

- Reduced benefit limits during first year of coverage

ELIGABILITY FOR MEDICARE COVERAGE