Medical Expense Insurance

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?

$900.00. In this situation, the group insurance carrier will pay 90% of the covered loss after the deductible has been applied.

How is a health provider reimbursed if they do NOT have an agreement in place with the insurance company.

A usual, customary and reasonable fee. When a provider does not have an agreement with the insurer for payment, they will be reimbursed a usual, customary, and reasonable fee.

Medical Expense Insurance would cover:

An injury occurring at the insured's residence

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

Deductible. A deductibles is a stated initial dollar amount that the individual insured is required to pay before insurance benefits are paid.

All of the following are characteristics of a major medical expense policy EXCEPT:

Elimination period. The elimination period is the period of time between the onset of a disability, and the time you are eligible for benefits. It is typically a characteristic of disability policies, not major medical expense polices. -Exceptions include: -Large benefit maximums -Deductibles -Coinsurance

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

Integrated deductible

A dread disease policy is considered to be a type of:

Limited health insurance policy. It required limited coverage for a specific injury(s) or illness. Such examples include travel accidents, dread disease, and hospital income.

When an insured has a major medical plan with first dollar coverage, how does this impact the benefits paid?

No deductible payment is required. A health insurance plan with first dollar coverage means no deductible payment is required before expenses are reimbursed.

A health insurance policy will typically cover:

Preventative health services

Who is the individual paid on a fee-for-service basis?

Provider

Major Medical expense plans provide coverage for each of the following EXCEPT:

Work-Related injuries. Work-related injuries are typically covered by Workers Compensation Insurance. -Exceptions include: -Medically necessary surgery -Diagnostic test -Blood and urine lab screens

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?

$140.00. Because the insured has previously met her deductible, the eligible expenses for a claim is the entire $175.00. The insurance company pays 80% of $175.00, or $140.00.

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?

$200.00. Because this policy has a zero deductible, the insured is only responsible for the 20% coinsurance on this claim, or $200.00

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?

$5,000. The insured will pay the stop-loss limit of $5,000.

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?

$50.00. In this situation, the insured will have to pay a $25.00 deductible plus $25.00 coinsurance which equals $50.00.

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?

$700.00. In this situation, the insured will pay $500.00 deductible plus $200.00 coinsurance therefore equaling $700.00.

A fee for service health insurance plan will normally cover:

A disease

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. A calendar-year deductible is paid before any benefits are paid in a calendar year.

Which of the following statements is NOT true regarding a Critical Illness Plan?

Coverage is limited to a single devastating disease. There are normally a number of "critical illness" that a critical illness plan will cover. -Exceptions include: -Pays a lump sum to the insured upon the diagnosis of a critical illness. -The insurer may have a list of critical illness they will cover -Also known as specified disease plan.

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

Dread Disease insurance. Dread disease insurance provides benefits for ONLY specific types of illness such as cancer or stroke.

All of the following are qualifications for establishing a health savings account (HSA) EXCEPT:

Enroll in a health plan with a prescription drug benefit. Establishing an HSA does not require to do so. -Exceptions include: -Enrolled in a high deductible plan -Be under the age of 65 (not enrolled in Medicare) -Enrolled in a health plan that limits out of pocket expenses

All of the following plans allow for employee contributions to be taken on a pre-tax basis EXCEPT:

Health Reimbursement Arrangement Plan (HRA's). Not for employees. -Exceptions include: -Selection 125 Plan -Premium Only Plan -Cafeteria Plan

Which of the following is NOT included under a health benefit plan?

Hospital Indemnity Plan. -Exceptions include: -Major medical policy -Basic hospital policy -Surgical Expense policy

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

Hospital Indemnity. A hospital indemnity policy pays an amount per day for hospitalization directly to the insured regardless of the insured's other health insurance.

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:

Indicated a preexisting condition.

Low frequency diseases can be exclusively covered by what kind of health insurance policies?

Limited polices. Health insurance that can be purchased to cover specific low frequency disease are called limited polices.

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

Tax-Free.

"Maximum benefits" refers to the:

Upper limit of the total lifetime benefits the insurance company will pay. The term "maximum benefits" refers to the upper limit of the total lifetime benefits the insurer will pay.