Flashcards
The acronym for social security, sometimes seen as OASHI.
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.
The age of the insured when they originally purchased the life insurance policy.
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)
A term rider, covering a family member other than the insured, attached to a whole life policy covering the insured.
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.
The owner of a life policy has the right to pay the premium, the right to select and/or change the beneficiary, the right to take a loan, and the right to choose a non-forfeiture option (such as cash surrender). The owner may or may not be the insured. The owner does not have the authority to change a policy provision.
This event occurs when a life insurance policy will not require any further premiums to keep the coverage in force.
Additional amounts of life insurance purchased using dividends; these insurance amounts require no further premium payments.
Expressed as a percentage of a person’s total disability income benefit. A person who cannot work full-time has a partial disability.
A partial surrender occurs when the owner takes a withdrawal from the cash value portion of the life insurance policy. When the owner does this the policy death benefit is permanently reduced, and there are no interest payments.
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.
The payor benefit rider is a rider that may be added to a juvenile life insurance policy. With the payor benefit rider if the payor should die or become disabled the policy will remain in force until the child reaches the age of majority in their state (18 or 21), or the payor is no longer disabled, whichever is first. When the payor benefit rider is enacted the juvenile life policy remains in force even though the premium is not paid.
Death proceeds are split equally among the living primary beneficiaries.
Under the per stirpes rule if one of the primary beneficiaries has died before the insured when the insured dies the proceeds are paid amongst the living primary beneficiaries, and the deceased beneficiary’s share is paid to their living decedants.
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.
An advance made by a life insurance company to a policy owner. The advance is secured by the cash value of the policy.
The amount paid on a life insurance policy at death or when the policyowner receives payment at surrender or maturity.
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 person who owns a life insurance policy. This is usually the insured person, but it may also be a relative of the insured, a partnership, or a corporation. The policy owner usually is the one who pays the premium and is the only person who may make changes to a policy.
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.
A risk whose physical condition, occupation, avocation, mode of living, and other characteristics indicate a long life ahead.
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.
The three main factors considered when determining the premium for life insurance include; mortality, interest, and expenses.
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.
The primary beneficiary is the beneficiary that will receive the life insurance policy proceeds when the insured dies.
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.
Net amount of money paid by the insurer to the beneficiary upon the insured’s death, or at policy maturity.
A general term applied to an agent, broker, or other person who sells insurance.
A qualified retirement plan that may be set up by any size business. The business can also have other retirement plans. A profit-sharing plan accepts discretionary employer contributions. There is no set amount that the law requires the business to contribute. The business can contribute in some years, on not in others. When the business does make contributions there must be a set formula for determining how the contributions are divided. This money goes into a separate account for each employee. A profit-sharing plan can be simple or complex. Profit-sharing plans must file a Form 5500 annually.
No change of gain, only chance of loss. Pure risk is insurable.
Qualified plan refers to employer-sponsored retirement plans that satisfy requirements in the Internal Revenue Code for receiving tax-deferred treatment. Qualified plans follow ERISA.
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.
The process of charging a substandard risk a higher premium, assuming that they are older than they are.
A policy issued at a higher premium to cover a person classified as a greater-than-average risk, usually due to impaired health or a dangerous occupation.
Determined by the underwriter, the insured’s rating is their premium classification for life or health insurance.
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.