102-5 Health Ins, Medicare, Medicaid Flashcards Preview

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Flashcards in 102-5 Health Ins, Medicare, Medicaid Deck (23)
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Indemnity coverage (traditional plans)

Aka first dollar coverage

Generally don’t include a deductible or coinsurance but reimburse the insured (from the first dollar of loss)

Examples: hospital expense coverage, surgical expense coverage, physician’s expense coverage


Major medical plans

Often underwritten as group plans

Designed to provide broad coverage for all reasonable and unnecessary expenses associated with an illness or injury, wherever it may have occurred to the insured individual

Include deductible and coinsurance


Maximum out-of-pocket (MOOP)

The max amount the insured will pay, which includes the deductible and the coinsurance amounts


National Association of Insurance Commissioners (NAIC)

The group developed model legislation specifying 12 provisions that must be included in health insurance policies, as well as several optional provisions to help create uniformity in health insurance contracts


Primary care physician (PCP)

Aka “gatekeepers”

Initially consult w/ patients regarding health issues and coordinate any other specialized care the patient needs


Health Maintenance Organization (HMO)

A prepayment organization that provides a broad range of health services to its group of subscribers for a fixed monthly fee

The medical providers receive a monthly fixed payment for each enrolled patient called the capitation fee


Preferred provider organization (PPO)

Similar to an HMO except that members are allowed to receive care outside the network of PPO doctors and hospitals


Point of service plans (POS)

Includes a network of participating providers and other policies of a managed care plan, but also include indemnity-type benefits for patients receiving services from nonparticipating providers


Archer Medical Savings Accounts (Archer MSAs)

-Established by HIPAA in 1996
-Since replaced by HSAs
-New Archer MSAs can no longer be established
-existing archer MSAs can still be maintained

Earnings tax-deferred until distribution, distributions used for qualified medical expenses are not taxable

Distributions not used for qualified medical expenses are taxable and subject to an additional 20% penalty if made before age 65


Health Savings Account (HSA)

Features the concept of combined a high-deductible health insurance policy (HDHP) with a tax-free savings account to be used in payment of individual qualified medical expenses

Distributions tax-free if used to pay qualified medical expenses
Otherwise taxable and subject to a 20% penalty unless the owner is at least 65 years or disabled or has died


Health Reimbursement Arrangement (HRA)

A participating employee is reimbursed medical expenses by an employer
Managed by 3rd party

Any unused amounts may be carried forward for reimbursements in later years

Self-employed individuals may not have HRAs


Income tax implications of health insurance

Health insurance premiums paid by an employer through an employer-paid group plan are a deductible business expense to the employer, and the benefits are not included in the employees’ gross income


Consolidated Omnibus Budget Reconciliation Act (COBRA)

Requires certain employers to provide previously covered individuals (including spouses and dependents) w/ the same health insurance coverage they received while employed after the occurrence of a qualifying event

-Termination: 18 months
-Death: 36 months for spouse, dependents
-Divorce: 36 months for spouse, dependents
-Loss of dependent status: 36 months
-Employee eligible for Medicare: 36 months from date of eligibility
-Employee meets social security definition of disability: 29 months

Employers with > 20 employees must provide COBRA

Up to 102% - premiums for employee


Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Addressed issue of preexisting conditions when switching jobs

Provided that there cannot be enforcement of a preexisting medical condition if:
-an employee was covered by the prior employer’s health insurance plan for at least 12 months
-fewer than 63 days have elapsed since the loss of coverage under the prior employer’s plan

Definition of preexisting condition: any medical condition. That was treated or diagnosed within 6 months before enrolling in the new group plan


Employer mandate in 2010 Health Care Reform Legislation

Requires certain employers to provide qualifying health care coverage to their full-time employees and eligible dependents or be subject to monetary penalties

-applies to firms w/ > 50 employees
-employers need to offer coverage to 95% of their full-time employees and their eligible dependents



Federal gov insurance plan. Covers individuals:
-65 or over
-who have been receiving social security disability benefits for at least 24 months
-who are on kidney dialysis treatment and in end-stage renal failure


Medicare Financing

Medicare payroll tax of 2.9%, divided equally between the employer and employee
Levied on all earnings w/ no income limit to providing financing

Additional Medicare tax of 0.9% if the taxpayer’s wages, other comp, or self-employed income exceeds the thresholds

3.8% Medicare contribution tracking aka net income tax levied on net investment income of taxpayers w/ modified adjusted gross income exceeding applicable thresholds


4 parts of medicare

Part A: Hospital Insurance

Part B: Medical Insurance

Part C: Medicare Advantage Plan

Part D: Outpatient Prescription Drug Coverage


Medicare Part A

-hospital care limited to 90 days
-lifetime reserve of 60 additional days for individuals who have exhausted the initial 90 days
-skilled nursing care
-condition must expected to improve
-home health services
-care in a hospice for the terminally ill


Medicare Part B

Requires monthly premium (not the case for Part A)


Medicare Part C

Health plan options that are part of the Medicare program which allows individuals to choose alternatives to Parts A, B, and D


Medigap policies

Supplemental health insurance policies standardized by the HIPAA legislation and identified in most states by the letters A through N for the types of benefits provided



A joint federal and state health insurance program designed to provide benefits for the indigent and impoverished

Look-back period of 60 months for assets transferred to others