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Accident And Health > Chapter 14 > Flashcards

Chapter 14 Flashcards

1
Q

What is the experience rating?

A

Using the actual claim experience of the individual employer to determine premiums

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2
Q

What are three primary components of a basic medical plan?

A

Daily room and board, surgical benefits, and miscellaneous benefits

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3
Q

What tax deductible savings account may only be used with a high deductible medical plan?

A

A medical savings account

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4
Q

Qualified withdrawals from a Health Savings Account are _________ withdrawals.

A

Tax free

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5
Q

Group insurance is a two party contract between ___________ and the __________.

A

Employer; insurer

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6
Q

T/F: the surgical section of a basic plan lists the most common operations in a surgical schedule.

A

T

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7
Q

Adhering to COBRA law is required if any employer with ______ or more employees.

A

20

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8
Q

List some examples of limited policies.

A

Hospital only, accidental death, travel accident, cancer only, credit, prescription, and vision

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9
Q

If a person is doubly covered by both Medicare and a group plan, which plan is normally considered primary?

A

The group plan

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10
Q

Group plan conversion must take place within ____ days after leaving the group.

A

31

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11
Q

COBRA law allows a former employer to charge a past employee _____% of premiums paid for medical benefit coverage.

A

102%

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12
Q

What are the characteristics of major medical plans?

A

High coverage amounts, deductibles, copayments, and blanket coverage

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13
Q

What is another name for outpatient services?

A

Ambulatory services

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14
Q

T/F: Murphy’s Law states that the larger the database of statistics, the more predictable losses will be.

A

F; this is the law of large numbers

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15
Q

T/F: Care of the root canal and pulp within the teeth is called endodontics.

A

T

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16
Q

What federal law provides 12 weeks of unpaid leave and a right to return to the same or similar job position?

A

The Family and Medical Leave Act

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17
Q

Who pays the costs that exceed the states policy benefit on a basic plan?

A

Costs that exceed the stated policy benefit in a basic plan are paid for by the insured policyowner

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18
Q

Describe a service plan.

A

Service plans are prepaid benefit plans that have a contractural relationship with doctors and hospitals

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19
Q

What is the certificate of coverage?

A

The verification of group participation given to enrolled employees

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20
Q

List the eligible groups for group insurance.

A

Employer related, trade associations, labor unions, and customer groups

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21
Q

The Age Discriminations in Employment Act does not allow for a reduction in _________ benefits.

A

Medical

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22
Q

What is the master contract?

A

A detailed description of the group plan that is given to the employer

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23
Q

If divorced, which parents medical policy would be required to provide coverage for children?

A

The policy of the parent with custody

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24
Q

What is another name for an indemnity medical plan?

A

A fee for service plan

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25
Q

What is adverse selection?

A

A bad risk or selection

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26
Q

The __________ the deductible amount, the less expensive the medical policy.

A

Higher

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27
Q

Comprehensive major medical combines what two types of policies?

A

Basic coverage and major medical

28
Q

T/F: Medical benefits for pregnancy related conditions are paid differently than other medical conditions.

A

F; benefits for pregnancy related conditions are paid in the same manner as other medical conditions

29
Q

T/F: care of the tissue surrounding the teeth is called periodontics.

A

T

30
Q

The Age Discrimination in Employment Act applies to employers with _____ or more employees.

A

20

31
Q

What is a common percentage of expenses an insured may pay for her coinsurance?

A

20%

32
Q

COBRA Law allows the dependents of deceased or divorced employees to continue their group benefits for up to ____ months.

A

36

33
Q

COBRA law allows a terminated employee to continue her group benefits for up to _____ months.

A

18

34
Q

HIPAA rules apply to employer groups of ____ or more employees

A

2

35
Q

A Basic Medical plan may also be referred to as a _______________.

A

First Dollar Coverage plan

36
Q

What federal law requires employers to provide a high degree of fiduciary responsibility to group plan participants?

A

ERISA

37
Q

What type of group plan requires employees to pay all or part of the premium?

A

A contributory group plan

38
Q

HIPAA law states that a preexisting condition may only be excluded from coverage for _____ months after group enrollment.

A

12

39
Q

Unless he is full time college student, a child’s group medical benefits end at what age?

A

The age of 26 is common in most states

40
Q

After a deductible has been satisfied, the insured may also be required to share the expenses by making a __________.

A

Copayment

41
Q

HIPAA law describes a preexisting condition as one that was treated within ____ months prior to group enrollment.

A

6

42
Q

T/F: An ongoing review of medical care is called case management.

A

T

43
Q

When does medical coverage on a newborn child commence?

A

At the moment of birth

44
Q

When would medical coverage end for a handicapped child who is dependent on his parents for all of his needs?

A

Provided the child doesn’t marry or obtain coverage through an employer, coverage remains indefinitely

45
Q

What is another name for case management?

A

Utilization review

46
Q

What are some examples of costs containment techniques?

A

Preventive care, alternatives to hospital confinement, and outpatient services

47
Q

What dental plans have deductibles, copayment, and pay benefits based upon a UCR value?

A

Nonscheduled plans

48
Q

Groups underwriting is _________ liberal than individual underwriting.

A

More

49
Q

Describe a stop loss feature.

A

A feature that limits the amount of expenses an insured may pay toward her medical bill

50
Q

When does a Notice to the Applicant regarding privacy issues need to be given to an applicant?

A

No later than when the policy is delivered

51
Q

Explain the concept of Coordination of Benefits.

A

This occurs when multiple policies pay in a particular order to eliminate overpayment of a claim

52
Q

What dental plan has no deductible or copayment and provides first dollar coverage on a predetermined basis?

A

Scheduled (basic) plan

53
Q

What is the dollar amount that must be paid by the insured prior to benefits being paid by their medical plan?

A

The deductible

54
Q

What are some of the goals of HIPAA regulation?

A

Standardizing the preexisting condition definition and increasing portability of existing coverage

55
Q

Describe community rating.

A

Using the claim experience of all
Local subscribers to determine premiums

56
Q

Normally, are individual medical premiums a deductible item?

A

No

57
Q

The Family and Medical Leave Act applies if an employer employs _____ or more employees within ____ miles of the worksite.

A

50;
75

58
Q

Medical expenses that exceed _____% of adjusted gross income may be tax deductible.

A

7.5%

59
Q

T/F: Employee paid group medical premiums are deductible to the employer.

A

T

60
Q

What is name for the diagnostic and preventative care of the teeth and gums?

A

Dental coverage

61
Q

Health savings account contributions are __________ to bother the employer and employee.

A

Tax deductible

62
Q

A health savings account must be used with a ________ deductible medical plan.

A

High

63
Q

Define the Doctrine of Comity.

A

The state in which the contract is delivered in the state of regulatory jurisdiction

64
Q

What type of plan is 100% employer paid for all eligible employees?

A

A noncontributory group plan

65
Q

Per HIPAA, if there has been no lapse of coverage ____+ days, previous coverage may be applied against the new plan.

A

63

Accident And Health (6 decks)

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