AD Banker Ch 6 & 7

Employers are the most common sponsors of this insurance.

• Probationary Period

• Blanket Insurance

• Mandatory Uniform Provisions

• Group Health Insurance

The review that determines whether provided or proposed health care services are or were medically necessary. This does not apply to emergency services but involves "before, during and after" medical services.

• Restrospective Review

• Precertification

• Utilization Review

• Concurrent Review

A review of claims for services already received. This review may be used to confirm medical necessity of services, identify coordination of benefits opportunities, and to determine if a non-pre-certification penalty applies.

• Prospective Review

• Utilization Review

• Retrospective Review

• Concurrent Review

This Act states employers with 20 or more employees must provide a health coverage continuation option to all covered employees and dependents up to 18 months in the event of:

Termination of employee (unless it is for cause as defined by federal law)

Reduction of hours for employee, so they no longer qualify as a full-time employee

Coverage may continue up to 29 months if an employee or dependent is totally disabled at the time of a qualifying event

• MEWAs

• Labor Unions

• COBRA

• PPACA

These were developed by the NAIC and must, by law, be included in every individual accident and health insurance policy. Different wording may be used as long as it is at least as favorable as the original wording. No additional provisions may be included which otherwise restrict or modify a uniform provision. There are 12 of these that are designed to protect the insured's interests.

• Mandatory Uniform Provisions

• Probationary Period

• Group Health Insurance

• HIPPA

A utilization review conducted prior to the delivery of the requested medical service. They include the initial review conducted before treatment starts, and the initial review for treatment to a different body part. During this review, copies of medical records may be required only when necessary to verify that the health care services being considered are medically necessary.

• Retrospective Review

• Prospective Review

• Concurrent Review

• Preventative Care

Covers a group of individuals whose membership changes frequently, such as students, passengers traveling on a common carrier, sports teams, volunteer firefighters, or other groups of people while being exposed to a specific risk. Blanket policies do not name specific individuals as insureds, the insured organization/business must certify a covered person's claim as legitimate. The term for a policy cannot exceed one year.

• Blanket Insurance

• Probationary Period

• Mandatory Uniform Provisions

• Group Health Insurance

Under this an employer always must maintain the employee's existing level of health coverage (including family or dependent coverage) under a group health plan during the period of this leave, provided the employee pays his or her share of the premiums.

• Precertification

• MEWAs

• FMLA

• METs

The Taft-Hartley Act was a 1947 amendment to the National Labor Relations Act of 1937. Among the provisions of the Act, these were permitted, under certain conditions, to establish primarily employer-funded trusts for the provision of health and welfare benefits to union members.

• COBRA

• Labor Unions

• Reinstatement

• Noncancellable

A utilization review conducted while services are being provided. The insurer monitors the insured's hospital stay to make certain that everything is proceeding according to schedule. The length of hospital stay is monitored.

• Precertification

• Prospective Review

• Concurrent Review

• Retrospective Review Retrospective Review