Accidental Bodily Injury
Unforeseen and unintended injury from an accident
Coinsurance
Cost-sharing by policyowner and insurer (percentage)
Deductible
Specified amount of money that the insured must pay for covered medical expenses before the insurance policy begins to pay
Pre-existing condition
A health condition/sickness that occurred prior to the issuing of a health policy
Total Disability
Unable to perform any occupation for which he or she is reasonably suited by reason of education, training or experience OR (more liberal) inability to perform the duties of ones own occupation
Partial Disability
Inability to perform one or more of the regular duties of one's occupation
Residual Disability
Provides benefits when a person returns to work after total disability, but is still not able to work near or at same levels as he/she worked before being disabled
Managed Care
Characteristics: Controlled Access of Providers, Comprehensive case management, preventive care, risk sharing, high quality care
Comprehensive
Covers all sickness or accidents that are not excluded
Attending Physician's Statement
A statement of how the applicant's medical conditions, diseases, and treatments obtained from applicant's doctor
Medical Information Bureau
made up of insurers, helps in underwriting
Disclosure Form
Must be provided at time of application or policy delivery
Workers Compensation
Offered and regulated by states. Accident or sickness that is work related. Benefits payable when a worker is injured by a work-related injury, regardless of fault or negligence
Workers Compensation (Types of) benefits
Medical, Income, Death, Rehabilitation
Agent, Applicant, Insured
Signatures required on health insurance application
Health contracts are...
conditional, unilateral, and of adhesion
Fee-for-service
Plans where providers receive a payment for billed charges for each service
Medical Expense Insurance
Reimburses policyowner for hospital and medical costs
Prepaid
Plans where providers are compensated regularly regardless of services provided
Basic (Hospital, Medical, Surgical)
Reimbursement insurance for medical expenses, First-dollar coverage (no deductible), Limited coverage
Major Medical
Reimbursement insurance for medical expenses, Deductible and coinsurance, larger benefit limits
(Health Maintenance Organization) HMO
Preventive Care, Service plan, prepaid basis, Limited service area and limited choice of providers, PCP = gatekeeper
(Preferred Provider Organization) PPO
Indemnity Plan, Fee for Service, Open Panel, no PCP
Elimination Period
Amount of time that must commence between onset of disability and benefits (essentially deductible in time)
Business Uses (of Disability Income Insurance)
Business Overhead Expense, Disability Buyout, Key-Person/Partner
Types of Group Health (Insurance Plans)
Individual employer groups, associations, Multiple-Employer Trusts (METs), multiple-employer welfare associations (MEWAs), customer groups; Small employer; Blanket insurance (insured members are not named); Contributory and noncontributory
COBRA
Required for employers with >20 employees, extends group coverage to terminated employees and dependents after qualifying event; employees pay 102% of premium; limited period of coverage; Applies to health insurance only (not life)
Cancellation
Standard Provision - insurer may cancel a policy within a specified period after issue by notifying insured in writing
Change of Beneficiary
Standard Provision - policyowner can change beneficiary with written request to the insurer, as long as beneficiary revocable
Change of Occupation
Standard Provision - insurer can adjust benefits for a more hazardous occupation
Claims Forms
Standard Provision - Insurer's duty to supply forms to the insured within a specified number of days after notice of claim
Insurance with other insurers
Standard Provision - insurers pay proportionate amount for any claim
Insuring Clause
Standard Provision - identifies basic agreement between insurer and insured
Notice of Claim
Standard Provision - insured's duty to to provide a notice to the insurer in the event of a loss
Payment of Claims
Standard Provision - specifies to whom claims will be made
Physical Examination and Autopsy
Standard Provision - insurer's right to examine the insured, at the insurer's own expense, if not prohibited by state law
Proof of Loss
Standard Provision - must be submitted within specified period of time after loss
Noncancellable
Cannot be cancelled by company nor can premium be increased
Cancellable
Allows insurer to cancel policy at any time or at end of policy period
Guaranteed Renewable
Cannot be cancelled by company, insurer has right to increase premiums on a class basis, not on an individual policy
Conditionally Renewable
Insurer may terminate the contract only at renewal and for certain conditions specified on the contract. Policy premium may be increased. Insurer may not deny renewal due to claims experience.
Optionally Renewable
Insurer may cancel the policy for any reason, on certain homogenous classes (not individuals within a class). Renewability is at option of the insurer, may decide not to renew on policy anniversary. If renews coverage, may also increase policy premium
Time of Payment of Claims
Standard Provision - Claims must be paid immediately upon proof of loss, but no later than the time specified in the policy
Unpaid Premium
Standard Provision - any past due premiums will be deducted from a claim
(Types of) Social Insurance
Medicare, Medicaid, Medigap, Social Security Disability Income Insurance
Initial Enrollment
The 7 month window for applying for Medicare immediately after eligibility starts
General Enrollment
Also known as open enrollment - Jan 1-Mar 31
Special Enrollment
Period during which individuals may elect to enroll in , modify, coverage, or transfer between healthcare insurance plans, usually without evidence of insurability or waiting periods because of specific work or life events.
Medicare
Federal medical expense insurance; Must be Age 65, chronic kidney disease, or SSDI eligible
(Medicare Supplement Policies) Medigap
Private insurance; fills in gaps like deductibles, coinsurance, benefit periods; Plan A - core benefits (offered in all of these plans); Guaranteed Renewable
Medicaid
State insurance program for individuals with insufficient income; funded by federal and state government; strict eligibility requirements
SSDI (Social Security Disability Income Insurance)
Must meet definition of disability, have proper insured status, and satisfy waiting period; amount based on insured's primary insurance amount (PIA)
Primary Insurance Amount
PIA, the amount single retirees receive in a monthly check if they retire at their retirement age
(Long-Term Care) LTC (Insurance)
Coverage requirements: >12 consecutive months, guaranteed renewable, elimination period, inflation protection, covers organic cognitive disorders (ex Alzheimer's, Parkinson's)
Skilled Care
Daily nursing & rehabilitative care
Intermediate Care
Rehabilitative care by medical personnel on a personal basis
Custodial Care
For meeting personal needs, help in performing activities of daily living
Home Health Care
Provided by a skilled nursing professional in the insured's home
30 days
Length of Medicare and LTC policies' "free look" period
Adult day care
Provided at recreation or community center for functionally impaired adults
Respite Care
Relief to family caregiver
Premiums not deductible, benefits tax free
Disability income (taxed?)
Premiums deductible above (7.5%) threshold
Medical Expense & LTC (taxed?)
Premiums paid by employer are tax deductible as a business expense, not taxable to employee; benefits attributable to employer's contribution taxable in group disability
Employer-Sponsored Group Health (taxed?)
Premiums not deductible, benefits tax free
Key-Person Disability & Disability Buy-Sell Insurance (taxed?)
Premiums deductible up to 100%
Sole Proprietors and Partners (taxed?)
5 days
If a consumer requests additional information concerning an investigative consumer report, how long does insurer/reporting agency have to reply?
Tax-deductible
Contributions to an HSA (taxed?)
65
Maximum dollar limit that must be provided for annual prostate cancer screening
Impairment (Rider)
Rider that excludes loss coverage for a defined pre-existing condition.
Guaranteed
A new employee who meets HIPAA eligibility requirements must be issued health coverage on what basis?
False
True/False - A reinstated policy provides immediate coverage for an illness
Capital Amount, Lump Sum
Anna loses her left arm in an accident covered by her Accidental Death & Dismemberment Policy. What kind of benefit will Anna most likely receive from this policy?
Stays with (the) employer
When an employee covered under a health reimbursement account changes employers, the HRA
Tax-Deductible
Contributions to an HRA (taxed?)
Indemnity
Type of hospital policy pays a fixed amount each day that the insured is in the hospital
As long as (the) policy is in force
How long does an insurer have to contest fraudulent misstatements made in a health insurance application?
(the) application (is) submitted
In insurance, an offer is usually made when
Free
Disability income benefits, including those for medical expense and LTC policies, are received income tax-_________
(The) foreign company
Commissioner is conducting an examination of a foreign company located outside Colorado. Who incurs costs?
50
The classification "small employer" means any person actively engaged in a business that during the preceding calendar year had no more than _____ eligible employees
Notice of Intent
Before a carrier can offer health benefit plans to small employers what must be filed to the commissioner?
Insurance Exchanges
The purpose of these is to administer health insurance subsidies and facilitate enrollment in private health insurance
(on the) first page of (the) outline of coverage
A notice stating a policy may not cover all long-term care costs incurred must be printed
60 days after submitting proof of loss
When can an insured initiate legal action against the insurer?
True
True/False: Coverage for newborns, mental illness and cervical cancer vaccines must be part of policies issued in CO
Insurer
Agent or insurer: Who can legally bind a contract?
(When an) insurer approves a prepaid application
When does acceptance typically occur?
Aleatory
of or pertaining to accidental causes; of luck or chance; unpredictable
18 Months
To convert to an individual policy, HIPAA requires that the individual have a previous continuous credible health coverage for at least
36 Months
What is the period of coverage for events such as death or divorce under COBRA?
Special Risk Policy
What special policy covers unusual risks that are not normally included under Accidental Death & Dismemberment coverage?
Attending Physician
Occasional Visits by which of the following medical professionals will not be covered under LTC's home health care? Attending physician; registered nurses; LPNs; Community-based organization professionals
Physician
Skilled nursing care is performed under the direction of a
Broader
In comparison to a policy that uses the accidental means definition, a policy that uses the accidental bodily injury definition would provide coverage that is... More Limited/Broader
Probationary Period
The period of time after a policy is in effect before claims arising from an illness can be covered
(Social Insurance Supplement) SIS or Social Security Riders
Supplement or replace benefits that might be payable under Social Security Disability
Defined Contribution
HRAs are: Defined Contribution/Defined Benefit
Presumptive Disability
Permanent disability due to total loss of sight, hearing, speech or use of 2 + limbs; benefits paid even while continuing to work.
20%
Penalty tax for nonqualified distributions from a health savings account
Dread Disease Policies
Cover medical expenses for a particular medical condition, such as cancer or heart disease
No
Basic Medical/Surgical/Hospital - Deductible?
Yes
Major Medical/Surgical/Hospital - Deductible?
Are not
HSA contributions made by an employer are/are not included in the individual taxable income
2 or more
HIPAA applies to groups of
Relative Value
Relative value system that determines coverage for a given procedure
Corridor Deductible
A deductible that must be paid before a policy can pick up where another left off
31 Days
When a disabled dependent child reaches the age limit for coverage, how long does the policyowner have to provide proof of dependency to remain covered?
Conversion Factor
Represents the total amount payable per point
Employers
Sets limits on contributions to HSAs
20 days
Under "Notice of Claim", written notice of claim must be submitted to insurer within
6 months
An insured suffering a relapse from the same disability within a ____________ period will b e covered as continued disability
30 days
All premiums received from insurers or credited by insurers to a producer's account must be credited to the insured's account within
31 Days
Parents must inform insurer of a newborn's birth within
15 days
After notifying the commissioner of terminated employment, how many days does the insurer have to mail a copy of the notification to the producer's last known address?
30 days
A nonresident producer moved from one state to another. How soon thereafter should he file a change of address and provide certification from the new state?
60 calendar days
A covered individual requesting an external review after being denied coverage must make a request within what time period?
(At the time of) initial solicitation
When must an outline of coverage be provided to a prospective applicant?
Disability Income Insurance
May be purchased through a group or employer; intended to replace lost income, also included in a comprehensive insurance program.
3-6 Months
The amount of time that can pass between the recurrence of an injury or illness for it to be considered a recurrent disability
65
At what age may an individual make withdrawals from an HSA for nonhealth purposes without 20% penalty?
Health Care Accounts, Dependent Care Accounts
Two types of Flexible Spending Accounts
HRAs
Available to employers of all sizes: MSAs/LPAs/HSAs/HRAs
The IRS
The annual contribution limit of a Dependent Care FSA is set by
Diagnostic and preventive care
An important feature of a dental expense insurance plan that is NOT typical of a medical expense insurance plan
63
Under HIPAA, the gap of coverage for eligibility is _____ or less days
(Usual, Reasonable, and Customary) URC Charges
Charges in which the insurance company will pay an amount for a given procedure based upon the average charge for that procedure in that specific geographic area
Renewal Provision
What health insurance provision describes the insured's right to cancel coverage?
20%
What percentage of covered charges above the deductible must the insured pay under Medicare part B?
5 Months
How long does a person have to wait after meeting requirements for disability benefits under Social Security before benefits will be paid?
$100
Maximum dollar amount that must be provided by insurance coverage for low-dose mammography screening
Group
Coordination of benefits is only found in (individual/group) health plans