Chapter 13 Flashcards Preview

LOMA 280- I STAR > Chapter 13 > Flashcards

Flashcards in Chapter 13 Deck (64):

what does medical expense coverage provide?

benefits to pay for the treament of an insured's illness and injuries.


who/what provides medical expense insurance coverage in the united states?

a private systems of commercial life and health insurance companies and other private health insurance providers offers individual and group coverage.


government-sponsored medical expense insurance programs in the united states are designed to coer who?

specifed people such ad elderl or the poor


how are countries like canada and the UK different?

almost every resident has medical expenses insurance coverage provided by government-sponsored programs.


Medical expense insurance coverage in the US is available in what 3 basic forms?

1. traditional medical expense insurance policies
2. managed care plans
3. government-sponsored health care programs


what are indemnity benefits provided by traditional medical expense insurance products?

contractual benefits that are provided based on the actual amount of the insured's financial loss.


how dose one typically receive reimbursment for their medical expenses?

after a person recieved medical service from a licensed provided of recognized services, the insured files a claim with the insurance company for the benefit.


What are the 3 basic types of coverage provided by traditional medical expense insurance?

1. basic medical expense coverage
2. major medical expense coverage
3. other medical expense coverage


basic medical expense coverage provides separate benefits for what 3 types of medical expenses?

1. hospital
2. surgical
3. physician expenses.


basic medical expense coverage typically provides first-dollar coverage. What does that meanh?

the insurer begins to reimburse the insured for eligible medical expenses without first requiring an out-of-pocket contribution from the insured.
- however benefits provided from these plans are typically limited


today, most health insurers offer major medical expense coverage. What does this provide?

substantial benefits for
1. basic hospital, surgical and physician expenses
2. addtional medical services related to illness or injury
3. preventative care.


what are the two types of major medical coverages available (think policies) (name them dont define)

1. Supplemental major medical policy
2. comprehensive major medical policy?


Define supplemental major medical polcy

policy issued in conjunction with underlying basic medical expense insurance policy.
-designed to provide benefit payments for expenses that exceep benefits of basic plan.


Define a comprehensive major medical policy.

combines the coverage provided by both a supplemental major medical policy and an underlying basic medical expensive policy
-substantial medical coverage under one policy.
- most polcies are this one


Name 9 basic covered services and treaments typically covered

1. hospital charges for room and board
2. miscellaneous inpatient hospital charges
3. surgical supplies and services
4. anesthesia and oxygen
5. physical, occupational and speech therapy
6. surgeons and physicians services
7. registered nurses' services
8. specific outpatient expenses, (labs, xrays, px)
9. preventative services (immunizations, periodic screening, and dx tests)


most maxium benefit amount payables for a particular service is based on the usual customary and reasonable (UCR) fee. What is this?

the amount that medical care providers within a particular geographic region commonly charge for a particular medical service.


what are the two most common forms of expense participation requirements?

deductible (flat dollar amount of eligible medical expenses ie. 500$- that insurer myst pay before the insurer begins baying benefits)
and coinsurance (specific percentage of all allowable expenses that remain after the insured has paid the deductable and must be paid by the insured)


most major medical expense policies contain a calandar-year deductible, what is this?

a deductible that applied to the total of all allowable expenses an insured incurs during a given calendar year.


The amount of money the insured must pay under the coinsurance provision is limited by the maximum out-of-pocket provision. Define this?

speficies that the policy will cover 100% of allowable medical expenses after the insured had paid a specified amount of out-of-pocket to satisfy deductable and coinsurance requirements.


what are 5 typical medical expenses that are usually excluded from major medical expense policy coverage?

1. cosmetic surgery (other than corrective)
2. treatment of illness or injury that occurs in acts of war
3. treatment of intentionally self-inflicting injuries
4. treament that is provided free of charge in a government facility or is paid by organizations
5. routine dental treatments, routine eye exams, corrective lenses.


Name 3 additional other medical expense coverages that are offered as a supplemental purchase.

1. dental expense coverages -typically provided under stand-alone dental expense policy
2. prescription drug coverage- usually requires the insured ot pay part of the cost of the px out-of-pocket at time of purchase. - can be covered under many major expense policies or as stand alone
3. vision care- coverage for one exam a year, - max benefit for eyeglass lenses/frames


what is managed care?

a method of integrating the financing and delivert of health care services within a system that manages the access to health care5 services and the cost of those service


what is the managed care plan?

the arrangement that integrates the financing and management of health care with the delivery of health care services to a group of individuals who have enrolled in the plan.


managed care plans typically require plan member to choose providers from within the network, they also encourage plan member to use a PCP. What is this?

primary care physician- a network member who cordinates members' medical care and treament.
- a pt will recieve basic medical care, preventative care, and wellness care directly through their PCP. without obtaining auth from the plan.
- to reciee specialized care a member must obtain a refer5ral.


Whats are the 3 types of managed care plans available?

1. HMO- health maintenance organization
2. PPO- preferred provider organization
3. POS -point of service plan.


In most managed care plans, how can a plan member receive comprehensive health care?

in exchange for payment of a fixed, periodic premium.
- covers the cost of most health care services no matter how often the member uses them
-also when a plan member receives service form a netowrk provided the plan member generally pays a specified, fixed amount, known as a copayment, to the provider.


how do manged care plans achieve risk sharing?

by negotiating fee arrangements with medical care providers and making other contractual arragements that encourage cost-effect care.
- if cost of service exceed sthe providers' negotiated fee the provider must absorb the loss. out of network providers are typically reimbured on a free-for-service basis.


managed care plan also manage health care costs by providing a variety of additional services designed to reduce the amount of medical care that plan member requires. What do they typically offer?

1. extensive preventative care programs.
2. access to wellness programs,
3. patient education programs,


what is the name of the publicly funded health care system available to nearly al residents in the UK?

national health service


US provides medical expense insurance benefits thorugh several grovernment proram including medicare and medicaid. Define these two

1. medicare- provides medical expense benefits to persons >65 and eprsons with disabilities.- its minimal
2. medicaid - provides basic medical expense and nursing home coverage to low-income individuals and certain ages and disabled people.


what does disability income coverage provide?

income replacement benefit to an insured who is unable to work because of sickness or injury.
-relieved financial stress created by disability expenses, by offering disability income coverage


what is a benefit period?

the time during which the insurer agrees ot pay income benefits to the insured.


what is short-term individual disability income coverage?

provides a maximum benefit period ranging from one to five years.


what is long-term individual disability income coverage?

provides a maximum benefit period of > 5yrs. extends until about age 65.


what is short-term group disability income coverage?

provides maximum benefit period of one year or less (usually has a max benefit period of 13- 26- 39 weeks)


what is long-term group disability income coverage?

provides max benefit period of more5 than one year. max benefit to normal retirement are or 70.


what is the current usual definition of total disability (both parts)

1. the disability prevent her from preforming the essential duties of her regular occupation. At the end of the specified period after the disability begins, (2-5 yrs) an insured is considered totally disabled if the disability prevents her from working any occupation for which she is reasonably fitted by education, training or experience.


what is the other total disability definition which is included more often in individual policies than in gorup?

the inability to perform the essential duties of the insured's own previous occupation.
- using this definition specify that benefits will be paid even while in insured is gainfully employed by another occupation.
-sold to those employed in certain professional occupations.


what is a presumptive disability?

stated condition that, if present, automatically causes the insured to be considered totally disabled.
- ie blindess, loss of any two limbs, and loss of speech or hearing.


what is an elimination period, which is often referred to as a waiting period?

specified amount of time that the insured myst be disabled before becoming eligible to receive policy benefits.


how long are typical elimination periods?

30 days to 6 months. its usually related to the length of the max benefit period.


are they elimination periods on group short term disability income policies"?

none on accidents
one week on sickness


are they elimination periods on group long term disability income policies?

30d-6 mo.


are disability income benefits amounts equivalent to salary?

no, or else people would never have the incentive to return to work


what two methods are used to establish the amount of disability income benefit that will be paid to a disabled person?

1. income benefit formula
2. flat benefit amount
- method depends on weather coverage is group or individual, and short vs. long term


what is expressed in the disability income formula?

expresses amount as a stated % of the insured's pre-disability earning and considered all sources of disability income that the disabled receives.
- 60-75%


does short or long term disability policies offer a higher percentage of income?

short (90-100%)


what are included in supplemental disability benefits ( which are available in connection with disability income policies)

1. partial disability benefits
2. future purchase option benefits


what is partial disability

a disability that prevents the insured either from performing some of the duties of his usual occupation or from engaging in that occupation on a full-time basis.


what is a future purchase option benefit?

grants the insured the right to increase the benefit amount in accordance with increases in the insured's earnings.
- insured usually myst prove a commensurate ^ in income, and usually is capped at a max


what is the COLA benefit (cost of living adjustment)

provides for periodic increases in the disability income benefit amount that the insured will pay to a disabled. Usually corresponds to the ^ in COL


what are 4 exclusions one will typically see with disability income policies?

1. injuries or sickness d/t war
2. intentionally self-inflicting
3. injuries received as a results of participation in a riot or the commission of a crime
4. occupation related disabilities, or illness where the insured is able to receive compensation from government program.


what is key person disability coverage ?

provides benefit payments to the business if an isnured key person becomes disabled.


what is disability buyout coverage?

provides benefits desgined to fun the buyout of a partners' or owners' interest in a business should he beome disabled.


what is the purpose of LTC coverage?

provides benefits for medical and other services to insureds who care for an extended pe5riod in their own homes or in a qualified facility.


LTC insurance policies typically contain benefit triggers. What are these?

requirements specifyin g the conditions that establish an insured's eligibility to receive long-term care benefits.


when are LTC benefits usually payable?

if the insured either loses his physical function capacity to perform at least a specific number of activities of daily living without assistance or has sever cognitive impairment.


what are ADLS (activities of daily living)?

the activities of eating, bathing, dressing, continence, toiletting and transferring in and out of bed, chair or wheel chair.


what is cognitive impairment?

reduction in persons ability to think, reason or remember.
- ie. AZ and dementia.


what kind of care may be paid by the LTC coverage?

diagnostic, preventative, therapeutic, rehabilitative, maintenance, or personal care services.


LTC insurance policies generally state a daily benefit amount. What is this?

the maximum amount of benefit payable for each day of an insured's long term care at a care facility of in the patients home.
- range from 50-500$


long term care policies generally determine the amount of benefit payable according to either the indemnity method or the reimbursement method. define these two.

1. idemnity- insurer pay the insured the daily benefit regardless of the actual expenses.
2. reimbursement- the insure5r pay the insure5d the amount of covered LTC expenses per5 day up; the the daily max.


some LTC insurance policies contain an inflation protection provision. How does it work?

it either automatically increases the benefit each year by a % or allows the insured to opt for a higher daily benefit amount at specified intervals without need of evidence.
- may be provided by means of a rider to an LTC policy


what is the typical elimination period for LTC policies?

0-100 days.
group LTC policies have a set elimination period of 90 days.