Health Insurance - Chapter 3: Medical Expense Insurance

the first portion of a covered Major Medical insurance expense that the insured is required to pay is called the...?

initial deductible

what are characteristics of a Health Reimbursement Arrangement (HRA)...?

it is entirely funded by the employer, it can be offered with other health plans, reimbursement for eligible medical expenses are allowed

what is NOT considered a limited benefit plan...?

life insurance policy

what is NOT included under hospitalization expense coverage..?

surgical fees

true statements about Major Medical benefits...?

the deductible can be expressed as a fixed dollar amount, the benefit period begins only after a specified amount of expenses have accrued, benefits are generally expressed as a percentage of eligible expenses

what best defines usual, customary, and reasonable (UCR) charges..?

the maximum amount considered eligible for reimbursement by an insurance company under a health plan

major medical expense plans...?

usually carry deductibles, coinsurance, copayment requirements and have large benefit maximums, coverage for inpatient and outpatient hospital expenses

A major medical policy typically contains a provision that required the insurer to pay only part of the loss, while the balance is paid by the insured. This provision is called...?

Coinsurance

A Hospital/Surgical Expense policy was purchased for a family of four in March of 2013. The policy was issued with a $500 deductible and a limit of four deductibles per calendar year. Two claims were paid in September 2013, each incurring medical expenses in excess of the deductible. Two additional claims were filed in 2014, each in excess of the deductible amount as well. What would be this family's out-of-pocket medical expenses for 2013?

$1000

M has a Major Medical insurance policy with a $200 flat deductible and an 80% Coinsurance clause. If M incurs a $2,200 claim for an eligible medical expense, how much will M receive in payment for this claim?

$1600. $2200 - $200 deductible x 80% = $1600.

An individual has a Major Medical policy with a $5000 deductible and an 80/20 Coinsurance clause. How much will the INSURED have to pay if a total of $15000 in covered medical expenses are incurred?

$7000. $5000 + 20% of the remaining bill = $7000

comprehensive major medical...?

Combines the features of basic expense coverage and major medical coverage, sold as one policy Cover practically all medical expenses, hospital, physicians, surgical, nursing, drugs, laboratory tests, etc. Comprehensive major medical policies include a deductible, coinsurance, and are generally sold on a group basis

what is included under hospitalization expense coverage..?

daily room and board, intensive care, misc expenses

all of these are considered limited benefit plans...?

dental policy, critical illness policy, cancer policy

M is insured under a basic Hospital/Surgical Expense policy. A physician performs surgery on M. What determines the claim M is eligible for?

determined by the terms of the policy

What type of policy would only provide coverage for specific types of illnesses (cancer, stroke, etc)?

dread disease insurance

An insured covered by a group Major Medical plan is hospitalized after sustaining injuries that resulted from an automobile accident. Assuming the plan had a $1,000 deductible and an 80/20 Coinsurance clause, how much will the INSURED be responsible to pay with $11,000 in covered medical expenses?

$3000. $1000 deductible + 20% of the remaining bill = $3000.

C was injured while deep sea diving and requires a hospital stay. C has a Major Medical policy with a 80/20 coinsurance clause and a $400 deductible. What is the MAXIMUM C will pay if the covered medical expenses are $2000?

$720. $400 deductible + 20% of the remaining medical bill = $720.

to be eligible for a health savings account (HSA), an individual must be covered by...?

a high deductible heath plan (hdhp), must not be covered by other health insurance, must not be eligible for medicare, and cant be claimed as a dependent

J was reviewing her Health Insurance policy and noticed the phrase "This policy will only pay for a semi-private room." This is considered to be...?

an internal limit -- or a limit placed on the dollar amount of a certain service

A comprehensive major medical health insurance policy contains an Eligible Expenses provision which identifies the types of health care expenses that are covered. What would not typically be covered?

experimental and investigative services

this type of deductible provision waives the deductible for all family members after some of them have satisfied individual deductibles within the same year...?

family maximum deductible

Basic medical expense insurance...?

has lower benefit limits than major medical insurance

S wants to open a tax exempt health savings account (HSA). to qualify, federal law dictates S must be enrolled in a...?

high deductible heath plan (hdhp)

under a basic medical expense policy, what does the hospitalization expense portion NOT cover...?

hospital admin fees, surgeons fees, physicians fees

A comprehensive major medical health insurance policy contains an Eligible Expenses provision which identifies the types of health care expenses that are covered. What would service would typically be covered?

hospital charges, physician fees, nursing services

under a basic medical expense policy, what does the hospitalization expense portion cover...?

hospital room and board

what is true about a Health Reimbursement Arraignment (HRA)..?

if the employee paid for qualified medical expenses, the reimbursements maybe tax free

what type of situation does a critical illness plan cover?

leukemia

a catastrophic illness would be best covered by which health insurance plan...?

major medical

Major medical benefits normal have a...?

maximum limit

what can an individual use their medical flexible spending account to pay for..?

prescription drugs

basic medical expense policies..?

provide benefits up front without having to satisfy a deductible, has lower benefit limits

a major medical policy typically...?

provides benefits for reasonable and necessary medical expense, subject to policy limits