Pass The Oregon Health Insurance Test

A person who is approved for Social Security Disability Insurance (SSDI) benefits must wait 24 months to become eligible for Medicare. Exceptions are available, such as if the person had prior periods of disability. Those months of disability can be applied towards 24-month waiting period. Also, a person who was disabled within the previous 60 calendar months and people who were diagnosed with either ALS (Lou Gehrig’s disease) or end-stage renal disease can request a complete waiver of the 24 month period. Since Siddique was disabled during the preceding 60 months, the waiting period is waived.

SSDI is a United States government welfare program available to individuals who used to work, but can work no longer, due to a physical or mental impairment. SSDI recipients previously “paid into” the system through taxes on their income.

Medicaid is a federal-state partnership government program available in all states. It provides free or low-cost health care to people who meet the requirements. The federal and state governments share the funding. The level of benefits is determined by each state, and coverage and costs vary by state, but Medicaid programs have to adhere to federal guidelines. Depending on the specific program, payments can be made directly to the medical provider or a third-party administrator or insurance companies could manage the Medicaid program. Under the PPACA states had the option to expand coverage to additional persons in accord with federal guidelines.

A certificate of insurance (COI) is issued by an insurance company to provide proof that insurance coverage is in effect. The document also provides the coverage provisions, including the type of policy, the coverage terms, effective date of coverage and any limitations or exclusions. The COI could be used to provide proof that a certain type of medical procedure is covered.

An independent medical examination (IME) may be requested by an insurer to verify claims of an insured’s personal doctor. The IME doctor has not treated the insured before the IME. It is a second opinion.

A point of service plan (POS) combines characteristics of a health maintenance organization (HMO) and the preferred provider organization (PPO). In a Point-of-Service plan, members who obtain health services from plan providers are typically reimbursed 90-100% of the cost versus a non-plan provider where reimbursement is approximately 70%. The difference in the cost and reimbursement amount is paid by the insured. A POS is a type of managed care that offers less medical expense, but in exchange for limited choice of providers.

The main job function of underwriters, especially for accident or disability policies, is to evaluate and analyze the risk and exposures of applicants. Underwriters review several factors, including an applicant’s medical history, to determine the applicant’s risk level. The underwriter next determines the level of coverage to offer the applicant, and then rates the policy. The premium rate is then determined. Lastly, the policy is issued, which typically involves sending all plan documents, including the certificate of insurance (COI), to the selling agent. The agent then provides the documents to the applicant.

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provides employees and their dependents in a group health plan with the ability to access health insurance coverage for up to 18 months or more after leaving their employer if specific factors apply, so an employee who has left their employer can choose COBRA continuation benefits and get the same coverage if the employee is entitled to it. It is not the employers choice. Continuation coverage is allowed a “prequalifying event” occurs that results in a loss of coverage. Those “qualifying events” are:

-involuntary or voluntary termination or reduced working hours
-death of an insured
-legal separation or divorce resulting in the termination of coverage of the ex-spouse
-when a dependent child “ages out” (is too old) of coverage eligibility

To obtain an extension of COBRA continuation coverage for 18 additional months once the initial 18 months ends, a second qualifying event needs to occur or the qualified beneficiary must be found to be disabled by Social Security. Aside from the above qualifying events, an extension is available if the covered employee becomes eligible for Medicare. To obtain an extension, the qualified employee must notify the plan administrator and provide proof of the reason or of the disability determination by the social security administration.

HIPAA requires “covered entities” and “business associates” to comply with specific security and privacy requirements in order to ensure that protected health information (PHI) is kept confidential.

HIPAA covered entities include:

-health plans
-health care clearinghouse
-health care providers that electronically transmit health information for transactions regulated by HIPAA

“Health plan” refers to individual or group coverage, which pays for or otherwise provides health care related services. An employer is generally not a covered entity.

Also, as part of the insurance application process, the applicant must sign a Health Insurance Portability and Accountability Act (HIPAA) disclosure acknowledgement form, which advises the applicant that any personally identifiable health information obtained by the insurance company will be kept confidential by the insurance company. However, the disclosure explains that the insurance company is permitted to share the information with other entities necessarily related to the underwriting process. The disclosure also details how the applicant can obtain their own medical information, as well as the written process for terminating the HIPPA authorization.

Unearned Income is a person’s income that continues even if the person cannot work, such as investment income or interest payments. Unearned income may be used to determine the amount of disability benefits someone can receive.

A contract of adhesion is a contract that is provided on a “take-it-or leave-it” basis by an insurance company, though it is not a term limited to the insurance industry. Such a contract allows the insured to either accept or reject the contract. However, as a general rule of contract construction, any ambiguities in the contract are construed against the drafter of the contract (the insurance company) and in favor of the insured, meaning that the insured wil get the benefit of the doubt in the event that there is any confusion as to what a policy provision is supposed to mean. Such a theory encourages insurance companies to ensure that the policy terms are as clear as possible.

Gender cannot be considered when determining a health insurance policy premium for an individual policy, according to the Affordable Care Act. Age, location and tobacco use may be considered and can result in higher premiums. Premiums will generally be higher for tobacco users, older people and for geographic areas where the cost of health care is high.

Since her condition is covered by workers’ compensation, Rainer can ask to stay on her employer’s group health insurance policy while she is unable to work, but her employer’s health provider must still approve her request. If approval is not provided, coverage may still be available. She may be able to obtain coverage through COBRA or the Family and Medical Leave Act (FMLA) depending upon her condition.

Determining whether a payout is required is part of the claims process, which is handled by the claims department. Field underwriters generally do not perform such tasks. Field underwriting primarily involves procedures performed prior to issuing coverage, such as scheduling an interview with applicant, answering policy questions and delivering the policy to the insured.

A rider is an extra part of the insurance contract that could expand or reduce a policy’s benefits, conditions or coverage. A rider is part of the contract, which is a legally binding document.

Programming is a method used to calculate the amount of disability coverage that an individual requires.

An actuary is a mathematician who calculates the likelihood that certain events will occur and prices the policy of insurance based on the likelihood that the events will happen.

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provides employees and their dependents in a group health plan with the ability to access health insurance coverage for up to 18 months or more after leaving their employer if specific factors apply, so an employee who has left their employer can choose COBRA continuation benefits and get the same coverage if the employee is entitled to it. COBRA continuation coverage is allowed if a “prequalifying event” occurs that results in a loss of coverage. Those “qualifying events” are:

-involuntary or voluntary termination or reduced working hours
-death of an insured
-legal separation or divorce resulting in the termination of coverage of the ex-spouse
-when a dependent child “ages out” (is too old) of coverage eligibility

To obtain an extension of COBRA continuation coverage for 18 additional months once the initial 18 months ends, a second qualifying event needs to occur or if the qualified beneficiary must be found to be disabled by Social Security. Aside from the above qualifying events, an extension is available if the covered employee become eligible for Medicare. To obtain an extension, the qualified employee must notify the plan administrator and provide proof of the reason or of the disability determination by the social security administration.

A beneficiary is named by the policyholder to receive the benefits or a payout from an insurance policy. The three general types of beneficiaries are:

-Primary (a spouse) is the main beneficiary and is given priority over all other beneficiaries to receive the benefits or proceeds from the policy
-Secondary (a child) can receive the benefits or proceeds in the event that the primary beneficiary is deceased when the insured dies
-Tertiary (a grandchild) can receive the benefits or proceeds in the event that both the primary and secondary beneficiaries are deceased when the insured dies

A child of a deceased is generally a secondary beneficiary. A beneficiary is named by the policyholder to receive the benefits or a payout from an insurance policy. The three general types of beneficiaries are:

-Primary (a spouse) is the main beneficiary and is given priority over all other beneficiaries to receive the benefits or proceeds from the policy
-Secondary (a child) can receive the benefits or proceeds in the event that the primary beneficiary is deceased when the insured dies
-Tertiary (a grandchild) can receive the benefits or proceeds in the event that both the primary and secondary beneficiaries are deceased when the insured dies

The insured holds the renewability leverage in a guaranteed renewable policy. A guaranteed renewable policy allows the insured to renew a policy regardless of any changes to the insured’s health or general condition. The insurance company cannot reject a renewal request.

Optional renewability is a policy provision allowing the insurer to terminate the policy on the policy’s anniversary date.

A conditionally renewable policy permits the insurance company to terminate coverage if an event mentioned in the policy occurs, such as the insured reaching a specific age. The insurer controls the process. The insurer could also choose to raise the premium.