Chapter 15: Medical Expense Insurance

Medical Expense Insurance would cover an injury occurring at the insured's residence an injury occurring at work an injury caused by war elective surgeries

A)

Medical expense policies will typically cover which of the following? Injuries caused by accidents Routine dental care Prescription eyeglasses Voluntary cosmetic procedures

A)

Ted has a health insurance plan that requires him to pay a specific sum out of pocket before any benefits are paid in a calendar year. Which of these does his health plan have? Calendar-year deductible Coinsurance provision Stop-loss feature Integrated deductible

A)

The elimination period in a disability income policy serves the same purpose as a(n) ______ in a medical expense policy. deductible coinsurance HSA reimbursement

A)

Which of the following does specified disease insurance NOT cover? costs covered by medical expense insurance medical expenses that are noncovered incidental costs out-of-pocket expenses

A)

Low frequency diseases can be exclusively covered by what kind of health insurance policies? Limited policies Blanket policies Employer policies Restricted policies

A)

Distributions from a Health Savings Account (HSA) for qualified medical expenses are fully taxable tax-free partially taxable tax credits

B)

An insured under a Major Medical expense plan with a zero deductible and 80/20 coinsurance provision files a $1,000 claim. How much of this claim is the insured responsible for? $160 $200 $600 $800

B)

Which of the following terms is NOT associated with a Major Medical policy? Stop-loss Comprehensive Deductible Capitation

D)

"Maximum benefits" refers to the upper limit of the total lifetime benefits the insurance company will pay upper limit percentage of what the insurance company will pay for coinsurance upper limits of what the insured will pay in out-of-pocket expenses upper limits of what an insurance company will pay for any particular claim

B)

A pharmacy benefit covers prescription drugs derived from a list called a(n) administrative drug list drug formulary controlled substance list generic benefit manager

B)

Amy has a group medical policy through her employer with a $500 deductible and a 90% coinsurance provision. She incurs $1,500 in covered health care services. How much will her group insurance carrier pay? $500 $900 $1,000 $1,350

B)

A health insurance policy will typically cover injuries obtained from war elective cosmetic surgery preventative health services work related injuries

C)

A payment system for health care in which the provider is paid for each service given is called a blanket plan lump sum fee-for-service a prepaid arrangement

C)

A proposed insured for a health insurance policy was treated for heart disease within the past year. When applying for health insurance, the heart disease treatment does not count as a preexisting condition is not required to be reported on the application indicates a preexisting condition is irrelevant to underwriting

C)

All of the following are qualifications for establishing a health savings account (HSA) EXCEPT Enrolled in a high deductible health plan Be under the age of 65 (not enrolled in Medicare) Enrolled in a health plan with a prescription drug benefit Enrolled in a health plan that limits out of pocket expenses

C)

All of these are characteristics of a major medical expense policy EXCEPT large benefit maximums deductibles elimination periods coinsurance

C)

An insured has a health plan that pays established amounts in accordance with a list of injuries, surgical procedures, or other losses. This list is called a loss chart benefit summary benefit schedule coverage menu

C)

A dread disease policy is considered to be a type of hospital expense policy group health insurance policy major medical insurance policy limited health insurance policy

D)

A fee for service health insurance plan will normally cover vitamins and natural remedies cosmetic procedures gym membership a disease

D)

A policyholder has a major medical plan with a 80%/20% coinsurance and a deductible of $75. If the insured has previously met her deductible and receives a bill for $175, how much will the insurer pay? $35 $75 $100 $140

D)

An insured is protected from the expense of a catastrophic illness by which of the following health insurance provisions? Self-insurance Stop-loss Deductible Reimbursement

B)

When an insured has a major medical plan with first dollar coverage, how does this impact the benefits paid? No deductible payment is required Deductible specified in the contract is payable by the insured Insured must pay a percentage of covered losses An initial deductible plus a percentage of the remaining covered loss is owed by the insured

A)

Which of the following types of policies pays a stated amount for each day an individual is hospitalized? Hospital confinement indemnity Hospital endowment Short-term major medical Surgical expense

A)

An insured has a stop-loss limit of $5,000, a deductible of $500, and an 80/20 coinsurance. The insured incurs $25,000 of covered losses. How much will the insured have to pay? $500 $5,000 $5,400 $5,600

B)

An example of elective cosmetic surgery would be reconstructive breast surgery after a mastectomy removing excess fat from an insured's waistline surgery to correct a birth defect reconstructive surgery after suffering injuries from an automobile accident

B)

An indemnity plan pays both the insured and health care provider provides the insured a specific dollar amount for services pays the health care provider directly for services rendered is typically issued as a group plan

B)

At what point does a self-insured group qualify for stop-loss coverage? When the insured reaches an age stated in the policy When claims exceed a specified limit in a set period of time When claims exceed the policy's maximum lifetime benefit limit When the average claim amount exceeds the limit stated in the policy

B)

Jennifer is required to pay a specific sum out of pocket before any benefits are paid in a year. Her health policy most likely contains a(n) stop-loss provision deductible copayment out of pocket provision

B)

Kate has a Major Medical Plan with a 75/25 coinsurance and a deductible of $25. How much will she have to pay if she, not having met any of her deductible, visits the doctor and receives a bill for $125? $25.00 $50.00 $75.00 $100.00

B)

How is a health provider reimbursed if they do NOT have an agreement in place with the insurance company? With a contingent fee With a scheduled fee With a usual, customary, and reasonable fee With a reasonably appropriate fee

C)

Kim has health insurance with a deductible of $500 and an 80/20 coinsurance. How much will she pay if she incurs a loss of $1,500? $200 $500 $700 $1,300

C)

The focus of major medical insurance is providing coverage for critical illnesses only preventative care medical and hospitalization expenses doctor's visits

C)

What is considered the most common type of specified disease insurance policy? Multiple Sclerosis Heart disease Cancer Stroke

C)

What is the tax liability for employer contributions in Health Savings Accounts (HSA's)?\ Taxable as regular income to the employee Tax-deductible expense to the employee No tax payment needed Taxable to the employee when they exceed 7 1/2 % AGI

C)

What type of policy would only provide coverage for specific types of illnesses (cancer, stroke, etc)? MEWA Blanket insurance Dread disease insurance Disability insurance

C)

Which of the following is NOT included in comprehensive major medical plans? Maximum coverage limits Coinsurance First-dollar coverage Deductibles

C)

Which of the following is NOT included under a health benefit plan? Major medical policy Basic hospital policy Hospital indemnity plan Surgical expense policy

C)

Which of the following statements is NOT true regarding a Critical Illness Plan? Pays a lump sum to the insured upon the diagnosis of a critical illness The insurer may have a list of critical illnesses they will cover Coverage is limited to a single devastating disease Also known as Specified Disease Plans

C)

Which of the following types of deductibles would apply a single deductible to both medical and dental insurance coverage? Standard deductible Combined deductible Integrated deductible Blended deductible

C)

All of the following plans allow for employee contributions to be taken on a pre-tax basis EXCEPT Section 125 Plan Premium Only Plan Cafeteria Plan Health Reimbursement Arrangement Plan

D)

All of the these are examples of cost sharing in a health insurance policy EXCEPT Copayments Deductibles Coinsurance Coordination

D)

Health insurance policies typically contain a provision stating that insureds and their insurer will share covered losses in an agreed proportion. Which provision does this refer to? Internal limit Stop-loss Deductible Coinsurance

D)

Major Medical expense plans provide coverage for each of the following EXCEPT Medically necessary surgery Diagnostic tests Blood and urine lab screens Work-related injuries

D)

Major medical expense plans typically use a cost containment measure for emergency hospital care. This is referred to as a(n) capitation exclusion limitation deductible

D)

Major medical insurance will typically cover medical expenses that result from a crime committed by the insured a self-inflicted injury intoxication a negative reaction to prescribed medication

D)

The elimination period under a hospital indemnity plan is the period in which pre-existing conditions are not taken into consideration the period in which all deductibles are eliminated the specified number of days after an insurance policy's issue date during which coverage is not afforded for sickness the specified number of days an insured must wait before becoming eligible to receive benefits for each hospitalization

D)

What does a Hospital Confinement indemnity policy pay for? Pays for the entire cost of the hospital stay Pays for the deductible and coinsurance of the hospital stay Pays for cost of the hospital stay after the deductible and coinsurance has been met Pays a specified daily amount while the insured is confined to a hospital

D)

What does the term coinsurance refer to? The stated initial dollar amount that the individual insured is required to pay before insurance benefits are paid The amount the Federal government pays after the deductible is met A situation where two insurance policies cover the same claim After the deductible is satisfied, the percentage paid by the insured for the remaining covered expenses

D)

Which type of coverage pays an amount per day for hospitalization directly to the insured regardless of the insured's other health insurance? MEWA Mutual Group Hospital indemnity

D)

Who is the individual paid on a fee-for-service basis? Subscriber Administrator Insured Provider

D)