TL&H 13 - Medical Expense Insurance
A Health Reimbursement Arrangement MUST be established ___________?
By the employer
Which of the following types of health coverage frequently uses a deductible?
Major Medical policy
Comprehensive Major Medical policies usually combine ____________?
Major Medical with Basic Hospital / Surgical coverage
A Hospital/Surgical Expense policy was purchased for a family of four on 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?
$1,000
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?
$1,600
Q is hospitalized for 3 days and receives a bill for $10,100. Q has a Major Medical policy with a $100 deductible and 80/20 coinsurance. How much will Q be responsible for paying on this claim?
$2,100
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?
$3,000
J's Major Medical policy has a $2,000 deductible and an 80/20 Coinsurance clause. If J is hospitalized and receives a bill for $10,000, J would pay ____________?
$3,600
An individual has a Major Medical policy with a $5,000 deductible and an 80/20 Coinsurance clause. How much will the INSURED have to pay if a total of $15,000 in covered medical expenses are incurred?
$7,000
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
Which of the following medical expenses does Cancer insurance NOT cover?
Arthritis
All of the following statements about Major Medical benefits are true, EXCEPT __________?
Benefits have no maximum limit
B's policy provides coverage on an in-hospital basis only and contains a limited daily room and board benefit. Which of these policies does B have?
Basic Hospital
In order to establish a Health Reimbursement Arrangement (HRA), it MUST _____________?
Be established by the employer
Which of the following policy features allows an insured to defer current health charges to the following year's deductible instead of the current year's deductible?
Carryover provision
Which of the following BEST describes a Hospital Indemnity policy?
Coverage that pays a stated amount per day of a covered hospitalization
A Major Medical policy typically contains a provision that requires the insurer to pay only part of a loss, while the balance is paid by the insured. This provision is called ___________?
Coinsurance
This type of deductible provision states that should more than one family member be involved in a common accident, or suffer the same illness, only one individual deductible amount shall be applied.
Common accident deductible
Major Medical policies typically ___________?
Contain a deductible and coinsurance
A prospective insured completes and signs an application for health insurance but intentionally conceals information about a pre-existing heart condition. The company issues the policy. Two months later, the insured suffers a heart attack and submits a claim. While processing the claim, the company discovers the pre-existing condition. In this situation, the company will ___________?
Continue coverage but exclude the heart condition
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
A characteristic of a Preferred Provider Organizations (PPO's) would be ___________?
Discounted fees for the patient
Which of the following statements BEST describes the intent of a Coinsurance clause in a Major Medical policy?
Discourages overutilization of the insurance coverage
What type of policy would only provide coverage for specific types of illnesses (cancer, stroke, etc)?
Dread decease insurance
A comprehensive major medical health insurance policy contains an Eligible Expenses provision which identifies the types of health care services that are covered. All of the following health care services are typically covered, EXCEPT for ___________?
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
All of these characteristics of a Health Reimbursement Arrangement (HRA) EXCEPT ___________?
HRA is entirely funded by the employee
Basic Medical Expense Insurance ____________?
Has lower benefit limits than Major Medical insurance
S wants to open a tax-exempt Health Savings Account. To qualify for this type of account, Federal law dictates that S must be enrolled in a ____________?
High-deductible health plan
For which of the following expenses does a Basic Hospital policy pay?
Hospital room and board
Under a Basic Medical Expense policy, what does the hospitalization expense portion cover?
Hospital room and board
Which of the following statements about Health Reimbursement Arrangements (HRA) is CORRECT?
If the employee paid for qualified medical expenses, the reimbursements may be tax-free
The first portion of a covered Major Medical insurance expense that the insured is required to pay is called the ___________?
Initial deductible
T was treated for an ailment 2 months prior to applying for a health insurance policy. This condition was noted on the application and the policy was issued shortly afterwards.How will the insurer likely consider this condition?
Insurer will likely treat as pre-existing condition which may not be covered for one year
J was reviewing her Health Insurance policy and noticed the phrase "This policy will only pay for a semi-private room". This phrase is considered to be a(n) ____________?
Internal limit
Which of the following situations does a Critical Illness plan cover?
Leukemia
Which of the following is NOT a limited benefit plan?
Life insurance policy
In Major Medical Expense policies, what is the objective of a Stop Loss provision?
Limits an insured's out-of-pocket medical expenses
Basic Hospital and Surgical policy benefits are ___________?
Lower than the actual expenses incurred
A catastrophic illness would be best covered by which of the following health insurance plans?
Major Medical
The individual Health Insurance policy that offers the broadest protection is an __________ ___________ policy.
Major Medical
Generally, how long is a benefit period for a Major Medical Expense Plan?
One year
Deductibles are used in health policies to lower ___________?
Overuse of medical services
Which of these options can an individual use their medical flexible spending account to pay for?
Prescription drugs
A major medical policy typically __________?
Provides benefits for reasonable and necessary medical expenses, subject to policy limits
Which provision allows a portion of any used medical benefits to be restored following a particular amount of benefit has been used, or after the policy has been in effect for a particular period of time?
Restoration of used benefit
Which of the following statements BEST describes dental care indemnity coverage?
Services are reimbursed after insurer receives the invoice
Which of the following services is NOT included under hospitalization expense coverage?
Surgical fees
Which of the following costs would a Basic Hospital / Surgical policy likely cover?
Surgically removing a facial birthmark
Which of the following statements BEST defines casual, customary, and reasonable (UCR) charges?
The maximum amount considered eligible for reimbursement by an insurance company under a health plan
Which of the following phrases refers to the fees charged by a healthcare professional?
Usual, customary, and reasonable expenses