License Coach Health Section Live Cram Course Handout

Transcription

1 License Coach Health Section Live Cram Course Handout 174) Health Insurance Slide 175) Health insurance policies that provide specialized limited coverage, such as AD&D and dread disease. 176) In health insurance, individuals covered by prepaid health plans. Synonymous with member. 177) Medical Providers are paid a set amount per month regardless of how many patients they treat. Synonymous with prepaid basis. 178) Medical providers are paid for each service they provide. 179) Insurance designed to protect against the severity of financial loss due to illness, disease, short- or long term disability, wages lost while ill or disabled, and medical expenses. 180) Arrangement in which medical providers may treat any patient. 181) Arrangement in which medical providers may only treat patients that are part of the managed care plan. 182) Health insurance is provided by private commercial carriers and the government. Health insurance provided by the government is also referred to as social insurance and includes programs such as: 183) 501(c)(9) trusts can be used by charitable organizations to fund employee health benefit plans. Contributions to a 501(c)(9) trust are immediately and earnings grow 184) Notice of claims must be given to the insurer within of loss. If the insurer does not provide claim forms within of receiving notice, the insured may submit proof of loss on any form. 185) A standard provision for group life and health insurance, stating that a grace period of at least 31 days is allotted for nonpayment of premium during which period the policy remains in force.

2 186) The clause refers to $ And of the Premium 187) requires a disabling condition return within a certain period of time to be an extension of prior disability and not require another elimination period. 188) A is the time between the date of the policy and date coverage begins. 189) Payments the insured makes for benefits or services provided under the policy coverage. Sometimes called copays, these fixed- dollar payments are usually small ranging from $5 to $ ) The insurer pays an amount for each procedure or treatment based on the average charges in that geographic area. Payment method for nonscheduled plans. 191) How must an insured die in order for the beneficary to receive Double Indemnity? 192) These policies provide the insured the right to continuation of coverage by making timely payment of premiums.no changes in coverage or premiums are permitted without the insured s consent. 193) policies provide continuation of coverage to a specified age subject to payment of premiums, but allows premium increases by classes of insureds. 194) These policies allow the insurer the right to not renew for any reason specified in the policy and premiums can be increased. 195) policies allow the insurer the right to not renew for any reason, and premiums can be increased. 196) These policies allow the insurer to cancel the policy at any time with notice, provided the insurer returns all unearned premiums. 197) What is the rider called that allows the insured to buy additional amounts of insurance without proof of insurability?

3 198) In how many days must the death occur?, after that they died from complications and Double Indemnity will not pay. 199) What ages must the insured be for the Guaranteed Insurability Rider? 200) A medical condition, whether physical or mental, resulting from accident or sickness preventing a person from being able to work. 201) Optional provision in health insurance policies which states the length of time between when sickness, accident, or disability begins and when benefits become payable. Often referred to as a time deductible. 202) is a condition such as loss of sight, hearing, speech, or loss of use of arms or legs, which qualifies as total disability, regardless of ability to work. 203) is the inability to perform one or more duties or the inability to work full- time. Partial disability benefits pay the portion of lost income(usually 50% of total disability benefits) for up to six months. 204) is when the insured returns to work after total disability, but is unable to perform some of his prior duties. Residual disability pays the difference in the insured s income before and after disability or 50% of total disability benefits. 205) is a condition for which the insured is not expected to recover, while prevents working during recovery or rehabilitation, but the insured is expected to recover. 206) Restricts the insured to indoors, while allows mobility. 207) The is the length of time the policy pays benefits to the disabled person. Policies with longer benefit periods are more expensive. 208) Covers the cost of medical treatments, physician s fees, hospitalization and other medical costs that ensue when the insured incurs an accidental injury or sickness. 209) The is the time between sickness, accident, or disability occurs and benefits become payable. are used in disability income and long- term care policies.

4 210) Requirement for full disability income benefits, typically inability to preform work duties. Each policy defines it differently. 211) Provision in disability income policies which prolongs the benefit period to the duration of the insured s life. 212) Optional benefit which waives the elimination period of a disability income policy if the insured requires inpatient hospitalization. 213) The Rider Guards against inflation, is an Increasing Term Rider. 214) Medical expense plans may pay benefits based on the type of procedure, or fixed amount. 215) They are limits placed on certain medical coverage's within a policy 216) Coinsurance provides for payment of service by the insurer and insured, usually and. 217) By contributing to these accounts, plan participants reduce their adjustable gross income, lowering their tax responsibilities. Contributions to these accounts are made on a pre- - tax basis; interest grows tax- - deferred. 218) The face amount of AD&D coverage which is paid out if the insured loses two limbs, two hands, two feet, vision in both eyes, or dies as a result of an accident. 219) Savings plans allow individuals to contribute pre- tax dollars to accounts that pay or reimburse the medical expenses of the person. These include,, HRAs and CDHPs. 220) The amount the insured must pay before the insurer will pay for a health insurance claim. 221) Government health insurance coverage for individuals over the age of 65, and special needs individuals. 222) Health insurance can be written individually or on a group basis. Most insurance is offered through group plans because it is often more affordable than individual coverage.

5 223) The group s ability to pay premiums and renew coverage. 224) are the payment of claims by multiple insurers. The primary insurer is responsible for payment of benefits according to its policy, while pay the remainder up to it s limit. 225) Primary care physician. 226) The first premium due on an insurance policy. Typically it is collected upon application submittal. 227) The benefits payment clause states how benefits are paid. Disability income benefits usually occur monthly while medical and AD&D benefits are 228) Maximum benefits limits cap payments made by the insurer, and they can be: Lifetime Per 229) Pays medical expenses for nondisabling injuries. 230) It allows members to consult other medical practitioners to obtain second and third opinions regarding the necessity of surgical procedures. 231) Is the payment method in which medical providers are paid a fixed fee per person no matter how many medical services are performed. 232) Health insurance coverage used to insure a debt. If a debtor becomes disabled, payments are made to a creditor until the insured can resume work. 233) Cost control program used by HMOs which utilizes primary care physicians also referred to as gatekeepers, utilization reviews, and prescription drug formularies. 234) Method of organizing an HMO. Physicians are employees of the HMO.

6 235) Geographic area to which HMO services and medical providers are limited. 236) Method of organizing an HMO. Similar to the group model, it contracts with two or more medical groups (instead of one) to provide medical services to HMO members. 237) Method of organizing an HMO. Functions like the group model except the HMO contracts with medical groups, physicians associations and independent physicians providing open panel services. 238) Method of organizing an HMO. The HMO contracts with one independent medical group to provide medical services to HMO members. Synonymous with group model and medical group model. 239) HMOs operate on this basis allowing members to use medical providers not authorized by the HMO. 240) Existing medical conditions for which the insured sought medical treatment or advice prior to policy issuance. 241) Early disease detection and health maintenance. Examples: annual physical exams and immunizations. 242) Medicare Parts A and B providing only hospital and medical coverage. 243) Medicare Part C plan managed by one or more medical providers. 244) Medicare prescription drug coverage. 245) Medicare managed care. Formerly known as Medicare + Choice. Also referred to as Medicare Advantage. 246) Medicare enrollment period - January 1st through March 31st annually. 247) Medicare eligibility period: six- month period spanning three months prior to reaching age 65 to three months after a person s 65th birthday. 248) Care provided in an individual s home. It usually includes intermediate or custodial care.

7 249) State and federally- funded medical assistance program for financially disadvantaged individuals. 250) These policies are intended to help individuals with daily activities they are no longer capable of performing themselves. Policy must provide coverage for at least 12 months (some states - 24 months).