Flashcards
It is this 1945 Act that exempts insurance from federal law to the extent that it is regulated by state law.
Insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Many states have expanded their Medicaid programs to cover all people below certain income levels.
An organization that collects medical data on life and health insurance applicants for member insurance companies.
A process used by insurance companies to try to figure out a person’s health status when they are applying for health insurance coverage to determine whether to offer you coverage, at what price, and with what exclusions or limits.
Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.
A federal health insurance program for people 65 and older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
A type of Medicare health plan offered by a private company that contracts with Medicare to provide an individual with Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. When a person is enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.
Medicare supplement insurance (Medigap) is extra insurance an individual can buy from a private health insurance company to help pay the out-of-pocket costs in Original Medicare. Generally, an individual must have Original Medicare – Part A (Hospital Insurance) and Part B (Medical Insurance) – to buy a Medigap policy.
A false statement of a material fact, accidental or intentional.
The frequency of premium payment is referred to as the mode of payment. The more often the premium is paid the more expensive it will be due to service fees.
Hazard arising out of an insured’s character, habits, financial responsibilities, etc. A liar represents a moral hazard.
Hazard arising out of an indifference to loss because of the existence of insurance. A careless person represents a morale hazard.
An insurance company owned by its policyholders. Mutual insurance companies usually issue participating policies. The policyowners of participating policies may receive dividends.
The association of state insurance Commissioners. They work together to solve insurance regulatory issues and form and recommend model legislation and requirements.
The facilities, providers, and suppliers a health insurer or plan have contracted with to provide health care services.
A policy that cannot be canceled by the insurer during the policy period.
An insurance company that is not licensed to operate within a state.
A life insurance policy that does not grant the policy owner the right to policy dividends. Nonparticipating policies are issued by stock insurers.
A requirement that describes the policyowner’s obligation to provide notification of loss to the insurer within a reasonable period of time.
For an insurance policy to be a legal contract it must include four elements. C – O – A – L. O stands for offer. In general, the applicant makes the offer when they fill out the application and submit the first premium payment.
A period of time when people can enroll in certain types of health insurance. The open enrollment period for a Marketplace plan is November 1 – January 15. For Medicare open enrollment is October 15th to December 7th each year. Job-based plans may have different Open Enrollment Periods. Enrollment in Medicaid or the Children’s Health Insurance Program (CHIP) is available at any time of year.
Original Medicare is a fee-for-service health plan that has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). After a person pays the deductible, Medicare pays its share of the Medicare-approved amount, and the enrollee pays their share (coinsurance and deductibles)
The most an insured has to pay for covered services in a plan year. After this amount is spent on deductibles, copayments, and coinsurance for in-network care and services, the health plan pays 100% of the costs of covered benefits.
Expressed as a percentage of a person’s total disability income benefit. A person who cannot work full-time has a partial disability.
A life insurance policy under which the company agrees to distribute to policyowners the part of its surplus that its Board of Directors determines is not needed at the end of the business year. The distribution serves to reduce the premium the policyowners had paid.
The law was enacted on March 23, 2010, and amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” refers to the final, amended version of the law. The law provides numerous rights and protections that make health coverage fairer and easier to understand, along with subsidies (through the “premium tax credit” and “cost-sharing reductions”) to make it more affordable. The law also expands Medicaid to cover more people with low incomes.
A peril is a cause of loss. Life insurance covers death due to two perils: accident and sickness.
A type of plan in which the insured will pay less if they use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require a referral from the primary care doctor to see a specialist.
The printed legal document stating the terms of an insurance contract that is issued to the policyowner by the company.
The terms or conditions of an insurance policy as contained in the policy clauses.
A 12-month period of benefits coverage under an individual health insurance plan. This 12-month period may not be the same as the calendar year. In group health plans, this 12-month period is called a plan year.
The time period during which an individual policy won’t pay for care relating to a pre-existing condition. Under an individual policy, conditions may be excluded permanently (known as an “exclusionary rider”). Rules on pre-existing condition exclusion periods in individual policies vary widely by state. Under the ACA, individual and small group medical expense policy sold on the Exchange cannot include a pre-existing condition exclusion period.
The time period during which a health plan won’t pay for care relating to a pre-existing condition.
Any condition (either physical or mental) including a disability for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the enrollment date in a health insurance plan. Genetic information, without a diagnosis of a disease or a condition, cannot be treated as a pre-existing condition. Pregnancy cannot be considered a pre-existing condition and newborns, newly adopted children, and children placed for adoption who are enrolled within 30 days cannot be subject to pre-existing condition exclusions.
A decision by a health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval, or precertification. A health insurance or plan may require preauthorization for certain services before they are received, except in an emergency. Preauthorization isn’t a promise the health insurance or plan will cover the cost. Preauthorization is also called prospective review.
A provider who has a contract with a health insurer to provide services to enrollees at a discount. Some policies cover all preferred providers and some have a “tiered” network and there is an extra charge to see some providers. A health insurance policy or plan may have preferred providers who are also “participating” providers. Participating providers also contract with a health insurer or plan, but the discount may not be as great, and the enrollee may have to pay more.
A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. An enrollee will pay less if they use providers that belong to the plan’s network. They can use doctors, hospitals, and providers outside of the network for an additional cost.
The payment, or one of the periodic payments, a policyowner agrees to make for an insurance policy. Depending on the terms of the policy, the premium may be paid in one payment or a series of regular payments, e.g., annually, semi-annually, quarterly, or monthly. The premium charged reflects the expectation of loss, expenses, and profit contingencies.
Health insurance or plan that helps pay for prescription drugs and medications. All Marketplace plans cover prescription drugs.
Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, diseases, or other health problems.
Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with an enrollee and advise and treat a person on a range of health-related issues. They may also coordinate an enrollee’s care with specialists.
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
An insurance policy shall not provide compensation to the policyholder that exceeds their economic loss. This limits the benefit to an amount that is sufficient to restore the policyholder to the same financial state they were in prior to the loss. Property and casualty policies and accident and health policies follow the principle of indemnity.
Approval from a health plan that may be required before getting a service or filling a prescription in order for the service or prescription to be covered by the plan.
A general term applied to an agent, broker, or other person who sells insurance.
Any health insurance that meets the Affordable Care Act requirement for coverage. The fee for not having health insurance no longer applies. This means there is no longer a tax penalty for not having health coverage.
Rebating occurs when the agent (producer) returns part of their commission to the insured as an inducement to buy the policy. Rebating is a prohibited trade practice under insurance law.
A disability that recurs within 90 days of when a person returns to work. There is no waiting period.
A written order from your primary care doctor for an insured to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), the insured must get a referral before they can get medical care from anyone except their primary care doctor. If they don’t get a referral first, the plan may not pay for the services.