Medical Insurance Flashcards
Comprehensive Medical
- insured pays yearly deductible
- insurer and insured pay co-insurance up to a certain amount (typically 80/20)
- After insured reached max out of pocket or stop loss limit, insurer pays 100%
Medicare Part A
Hospital Insurance
-65 or older/ or disabled receiving benefits for 2 years
-disabled widows of workers 50 or over
-benes 18 or older receiving benefits before 22
(disabled Part A and B)
Benefits
- Hospital deductibles 60/30/60 days max 150
- skilled nursing 100 days
- unlimited post hospital home health
- Hospice
- Patient pays first 3 pints of blood
Limitations
- Services provided outside us not covered (limited Canada, Mexico, Caribbean or US territorial waters)
- Secondary payer always
Medicare Part B
Voluntary
Monthly Premiums
80/20 no stop loss - deductible applies
Benefits
- Doctors Services
- Diagnostic tests, Radiology/pathology, mental illness, transfusions, PT/OT, Drugs and biologicals not self administered!!)
- Out Patient services for Dx and Tx illness or injury
- Unlimited home health
- Preventive care (free)
- Depression Screening, counseling alcohol, obesity, and behavioral therapy for CD
EXCLUDED dentures and dental glasses and hearing aids immunizations (other than flu shot) Prescription drugs
Medicare Part D
Must join a plan if you want coverage
Must have A and B
Medigap
Plans A-J
Generally pay 80%
Add benefits to cover deductible and coinsurance
HMO
Capitation - monthly fee in exchange for all medical care
Gatekeeper -PCP responsible for determining all necessary care
Disadvantage - Required to receive all care through physicians affiliated with HMO
Children can stay on parents policy until 26
PPO
Network of health care providers contracting with ins co
medical service at reduced fee
Different from HMO in that:
1. PPO generally fee for service not prepaid
2. PPO can go outside of network, higher cost/ coinsurance
Health Plan Taxation
Premiums tax deductible to employer
no income tax liability to employee
COBRA
EXEMPT- Small companies (fewer 20 employees 1/2 yr)
Plan Coverage
- > 20 employees more 1/2 previous yr
- full and part time employees count (part time count as fraction worked)
Events
1. Voluntary(includes retirement)/Involuntary termination or move to 1/2 time— employee and dependents - covered up to 18 months
2. Death divorce legal separation —spouse and dependents up to 36 months. divorce-children still on plan..they are not divorced
3. Loss of dependent status —children up to 36 mo
4. Disability - 29 months
* if disabled within 60 days of triggering event coverage extended 11 mo (29). Continuation is not automatic…must be elected
**must be participating in health plan to elect
May be 102% of actual ins (2% employer admin fee)
HIPPA
may move from one employer to another with no preexisting conditions clause if elected with/in 63 days since coverage was lost. Can use COBRA then pay HIPPA plan if don’t go back to work
Must have been covered for 12 mo on old plan
Does not apply to waiting periods - use cobra
HSA
Eligibility
Covered under High Deductible plan
No other health plans
Min and Max OOP
S$1300-$6550
F$2600-$13100
Contributions deductible (above the line adjustment)
$3350 S $6750 F
Grow tax deferred
Qualified distributions tax free (20% penalty)
Employer Contributions tax deductible no income to employee
$1000 Catch up over 50
Ordinary income after 65 for other than med expense
Qualified Expenses MD visits SX RX drugs (OTC and Vit not covered unless insulin) Acupuncture/Chiro Eye Hearing Dental Alcohol and Drug LTC
No payment for other ins except -COBRA -Health while on unemployment -Part A/B premiums and out of pocket -Medicare HMO -LTC ins No Medigap
MSA
Medical Savings Account
Custodial or Trust account established with High deductible plan.
No new plans after 12/2005. (sm employer or self employed previous calendar yr)
Distributions tax free
Only Employer or Employee contribute not both
Deductible
$2250-4450
$3350-8150
Tax Deduction
S 65% deductible
M 85% deductible
