chapter 3: Medical Expense

the individual health insurance policy that offers the broadest protection is a ________. _________ policy

Major medical

which of the following types of health coverage frequently uses a deductible

Major medical

comprehesince major medical policies usually combine

Major with basic hospital/surgical coverage

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

which of the following statements best describes the intent of a coinsurance clause in a major medical policy

discourages over utilization of the insurance coverage

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

dread disease insurance

a comphrehensive 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

which of the following is NOT a limited benefit plan

life insurance plan

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 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

generally how long is a benefit period for a major medical expense plan

1 year

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?

10,000 * .20+100=2100

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

10,000-2000=8000*.20+2000+3600

A Hospital/Surgical Expense policy was purchased for a family of 4 in 4/13. the policy was issued with a 500$ deductible an da limit of 4 deductible per year. 2 claims were paid in sept 2013, each incurring medical expense in excess of the deductible. two addition claims were filed in2012 each n excess of the deductible amount as well. what would be this family out of pocket medical expnedse

1000

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 15,000 uncovered medical expenses are incurred

15,000-5,000=10,000 *.20 +5000=7000

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?

2000-400=1600*.20+400+720

M has a major medical insurance policy with 200$ flat deductible and 80% coinsurance clause. if M incurs 2,200 claim for medical expense - how much will M recieve in payment for this claim

2200-200*.80=1680

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

this type of deductible provision states that should more than one family member be involve in a common accident, or suffer the same illness, only one individual deductible amount shall be applied

Common accident deductible

a characteristic of PPOs would be

Discounted fees for patient

all of these are chracteristics of a HRA except

HRA plans are employer funded medical reimbursement plans

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?

Insurers will likely treat it as a pre-existing condition which may not be covered for one year

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 medical expenses does cancer insurance not cover

arthris

In order to establish a HRA it must

be established by the employer

all of the following statements about major medical benefits are true except;

benefits have no max limit

a. health reimbursement arrangement must be established

by the employer

which of the following situations does a critical illness plan cover

cancer

which of the following policy features an insured to defer current health charges to the following year deductible instead of current year

carryover provision

a major medical policy typically contains a provision that requires the insurer to Pau only part of a loss, while the balance is paid by the insured. this provision is called

coinsurance

major medical policies typically

contain a deductible and coinsurance

a prospective insured completes and signs an application for health insurance but intentionally cancels information about a preexisting condition- company issues policy- 2 months later dude has a heart attack. while processing the claim ,company finds out- what will company do?

continue coverage but exclude heart condition

which of the following best describes a hospital indemnity policy

coverage that pays a stated amount per day of a covered hospitalization

this type of deductible provision waives the deductible for all family member 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 want to open a tax emempt 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 is correct

if the employee paid for qualified medical expenses , the reimbursements may be taxed free

the first portion of covered major medial insurance expense that the insured is required to pay is called

initial deductible

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

internal limit

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

major medical policy typically

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

which of the following best describes dental care indemnity coverage

services are reimbursed after the 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 define usual customary and reasonable charges

the max amount considered eligible for reimbursement under a health insurance plan

which of the following phrases refers to the fees charged by a healthcare professional

usual customary & reasonable expenses