Chapter 14: Health Insurance Providers

Question 1

Social Security OASDI Program

Answer 1

Federal government disability benefits
Cannot perform gainful work
Impairment must last at least 12 months or result in an earlier death.
5 month waiting period

Question 1

Medicaid

Answer 1

Titile XIX, added in 1965
Matching federal funds to states for their medical public assistance plans, regardless of age.
Low income, disabled or under 21.

Question 2

Multiple Employer Trusts

Answer 2

A method of marketing group benefits to employers who have a small number of employees.

Question 3

Multiple Employer Welfare Arrangement (MEWA)

Answer 3

A type of MET that consists of small employers who have joined to provide health benefits to their employees, often on a self-insured basis.
Tax-exempt.
Must have an employment related common bond.

Question 4

TRI-CARE

Answer 4

A federal government accident and health plan which provides accident and health coverage to military service and families.

Question 5

Consumer cooperatives

Answer 5

Incorporated or unincorporated organizations managed by an attorney-in-fact in which all members insure one another.

Question 6

Hospital indemnity vs Indemnity Plan

Answer 6

Hospital Indemnity = a plant that pays a fixed daily amount to the insured

Indemnity Plan = major medica insurance, traditional reimbursement.

Question 7

Managed Care

Answer 7

The process of controlling how policyowners utilize their policies.

Question 8

Cost Management Approaches used by insurers (4)

Answer 8

1. Mandatory second opinion
2. Precertification review
3. Ambulatory surgery
4. Case management

Question 9

Employer requirements for HMO (6)

Answer 9

1. 25+ employees
2. Employer must contribute
3. Employer cannot charge more than a commercial insurance plan
4. Employer must stress preventative care + cover family planning
5. Employ must maintain minimum reserves
6. Employ premiums must be established using a community rating approach

Question 10

Taft-Hartley Trusts

Answer 10

Negotiated trusteeships are formed as a result of collective bargaining between a union of employees and their employer.
Employers cannot pay funds directly to the labor unions.

Question 11

Non-contributory vs Contributory

Answer 11

Noncontributory: 100% employer sponsored, 100% participation

Contributory: Partially employer sponsored, 75% participation

Question 12

COBRA

Answer 12

14 days : employer tells employee
60 days : employee decidews
18 months : extended coverage
36 months : loss of dependents
29 months : loss of benefits due to disability

102% of premium

Question 13

FMLA

Answer 13

Covered employers must grant eligible employee up to 12 work weeks of unpaid leave for any of these reasons:
1. Brith
2. Placement of child for adoption
3. Care for an immediate family member
4. Medical leave

Question 14

Covered entity

Answer 14

An employer that engages in interstate commerce and has 15 or more employees