Chapter 7 - Medical Expense Insurance

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

$140, the company pays 80% of 175 -- 140

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

$5,000

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

$700, the insured will pay $500 deductible plus $200 coinsurance = $700

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 50 75 100

75, its 25 coinsurance+deductible 25

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

Calendar-year deductible

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

Coverage is limited to a single devastating disease

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

Dread disease insurance

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

Enrolled in a health plan with a prescription drug benefit

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

Health Reimbursement Arrangement Plan because employers contribute to HRA not employee

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

Hospital indemnity

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

Integrated deductible

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

Limited policies

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

No deductible payment is required, before expense are reimbursed

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

No tax payment needed

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

Provider

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

With a usual, customary, and reasonable fee

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

Work-related injuries

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

an injury occurring at the insured's residence

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 benefit schedule

benefit schedule, set pre-determined limits or max on how much money an insured can be reimbursed for a covered loss

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

deductible

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

drug formulary

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

elimination periods

which of the following is not included under a health benefit plan? MAJOR MEDICAL POLICY basic hospital policy hospital indemnity plan surgical expense policy

hospital indemnity plan

The focus of major medical insurance is providing coverage for

medical and hospitalization expenses

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

preventative health services

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

provides the insured a specific dollar amount for services

an example of elective cosmetic surgery would be

removing excess fat from an insured's waistline

Distributions from a Health Savings Account (HSA) for qualified medical expenses are

tax-free

The elimination period under a hospital indemnity plan is

the specified number of days an insured must wait before becoming eligible to receive benefits for each hospitalization