Ch 11: Healthy, Disability, and Long-term care Insurance
stop-loss is a provision under which an insured pays a certain amount, after which the insurance company pays ______% of the remaining covered expenses
100
the majority of people who draw on Medicare are _____ or older
65
most policies pay _____ of expenses above the deductible amount; the policyholder pays the rest.
75% to 80%
a "good" health insurance plan pays at least _______ percent of out-of-hospital expenses once a yearly deductible for the individual and family have been met.
80
a combination of hospital expense insurance, physician expense insurance, and surgical expense insurance is called _________.
Basic health insurance
a provision under which the insured pays a flat dollar amount each time a covered medical service is received is called:
Copayment
(T/F) most private insurance companies do not provide group policies.
False.
(T/F) Administration costs for health care in the United States are less than in nations such as Canada and Mexico.
False. Administration costs in the United States are much higher than in countries such as Canada.
(T/F) the hospital indemnity policy is a major medical protection.
False. hospital indemnity policies are intended to be only supplements to major medical protection.
a health insurance plan that provide a wide range of health care services for a fixed prepaid monthly premium is called a:
Health maintenance organization (HMO)
basic health insurance coverage is a combination of:
Hospital expense insurance surgical expense insurance physician expense insurance
_______ medical expense insurance pays most of the costs exceeding those covered by the hospital, surgical, and physician expense policies.
Major
a group of doctors and hospitals that agree to provide health care to members at prearranged fees is called _______.
PPO
______ work like HMOs, except the networks are managed by doctors and hospitals.
PPOs
HMO preventive care services include periodic checkups as well as _________.
Screening programs immunizations Diagnostic testing
a provision is major medical policies, also called an out-of-pocket limit provision, under which an insured pays a certain amount, after which the insurance company pays 100% of the remaining covered expenses, is called a :
Stop-loss
copayment is the provision under which the insured pays a flat dollar amount each time a covered medical service is received.
True
the exclusions and limitations provision may deny coverage for preexisting conditions, cosmetic surgery, or routine checkups.
True
The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 requires employers to offer employees and dependents, who would otherwise lose group health insurance, the option to continue their group health coverage for:
a certain amount of time
which of the following factors has not been attributed to increasing health care costs?
a focus on healthy living options
Health insurance is one way people protect themselves against economic losses due to __________.
accident illness disability
What are some of the factors that have led to increasing health care costs?
an increased number of crimes and accidents the use of expensive technologies duplication of tests and sometimes duplication of technologies that yield similar results increases in the variety and frequency of treatments, including allegedly unnecessary tests increasing number of accidents and crimes that require emergency medical services. limited competition and restrictive work rules in the health care delivery system labor intensiveness and rapid average earnings growth for health care professionals and executives
if your health insurer has denied coverage for medical care you received, you have the right to _______ the claim decision
appeal, dispute, or challenge
______ cuts down on paperwork and time by allowing your insurance company to pay the hospital before you receive the bill for them.
assigning benefits
a combination of hospital expense insurance, physician expense insurance, and surgical expense insurance is called __________.
basic health insurance
what qualifications must you have to be eligible for Medicare?
be 65 or older have certain disabilities people of any age w/ kidney failure
in terms of dollar amount or a number of days in the hospital, what determines the maximum amount paid?
benefit limits
name an independent, nonprofit membership corporation that provides protection against the cost of hospital care:
blue cross
which of the following is not a reason for the high and rising cost of health care?
built-in deflation of the health care system
a provision under which the insurer and insured share the covered losses is called _________.
coinsurance
which type of insurance is complete major medical insurance that has a very low deductible?
comprehensive
what provision prevents you from collecting benefits from two or more group policies that would in total exceed the actual charges?
coordination of benefits
long-term care is:
day-in, day-out assistance
health reimbursement accounts (HRAs) are tied to high _______ insurance policies.
deductible
which type of insurance provides reimbursement for the expense of services and supplies and encourages preventive care for teeth?
dental expense insurance
the exclusions and limitations provision specifies the conditions or circumstances for which the policy _______.
does not provide benefits
the benefit limits provision defines the maximum benefits possible in terms of either a(n) ______ amount or a number of ________ in the hospital.
dollar, cash, or monetary days, or day
identify ways in which you can personally reduce your health care costs.
eat a balanced diet to keep weight under control rest avoid smoking
age, marital status, and dependency requirements are usually specified in the ______ provision of an insurance policy.
eligibility
HMO basic health services include impatient, output, maternity, mental health, substance abuse rehabilitation, and __________ care.
emergency
the federal Consolidated Omnibus Budget Reconciliation Act of 1986 requires many employers to offer group health benefits to:
employees and dependents who would normally lose group health insurance.
administrative costs in the United States are much higher than those in other nations due to activities such as:
enrolling beneficiaries in a health plan paying health insurance premiums checking eligibility obtaining authorizations for specialist referrals filing reimbursement claims
aggregate limits are limits on the ______ amount of coverage.
entire, total, maximum, or full
a(n) ______ provider organization is one that renders medical care from only affiliated health care providers and will not reimburse for charges form nonaffiliated health care providers.
exclusive or epo
which organization renders medical care from affiliated health care providers?
exclusive provider organization (EPO)
what might a person who is uninsured experience during times of illness and injury?
financial burden
health maintenance organization (HMO) is a health insurance plan that provides a wide range of health care services for a(n) ________ monthly premium.
fixed prepaid
what do insurance company actuaries rely on to establish rates and benefits?
general statistical models
most private insurance companies are providers of _______ health insurance policies through employers.
group
under the guaranteed renewable policy provision, the insurance company cannot raise premiums unless it raises premiums for all members in your __________.
group, class, or plan
with a(n) ________ policy provision, the insurance company cannot cancel unless you fail to pay premiums when due.
guaranteed renewable
The Health Insurance Portability and Accountability Act of 1996 provided federal standards for ______ renewability.
guaranteed, assured, or certain
By exercising, not smoking, getting rest, and driving carefully, individuals can greatly reduce their ______.
health care costs
which of the following is a plan that is funded solely by your employer and gives you a pool of money to spend on health care?
health reimbursement account
Rising hospital care costs, new medical technology, and the increasing number of elderly people have helped make _______ one of the fastest-growing areas of the health care industry.
home health providers
when you assign benefits, you sign a paper allowing your insurance company to make payment to your ______ or _______.
hospital doctor, physician, or provider
when you assign benefits, you sign a paper allowing your insurance company to make payments to your ________ or _________.
hospital doctor, physician, or provider
which type of insurance pays part or all of hospital bills for room, board, and other charges?
hospital expense insurance
which type of policy pays benefits when you are hospitalized that are in cash and you can spend as you choose?
hospital indemnity policy
Blue cross is an independent, nonprofit membership corporation that provides protection against the cost of __________ care.
hospital, medical, or health
Medicare ________ insurance is financed from a portion of social security taxes.
hospital, or hospitalization
Preventative care for an HMO includes checkups, screening, diagnostic testing, and routine ______.
immunizations, shots, immunization, vaccines, or vaccination
an ______ policy provides specified benefits regardless of whether the actual expenses are greater or less than the benefits. A ________ policy provides benefits based on the actual expense.
indemnity reimbursement
basic health services for an HMO include inpatient and outpatient services such as ____________.
inpatient, outpatient, maternity, mental health, substance abuse, & emergency care
_____ is the process of paying a premium in exchange for financial protection.
insurance
______ is the process of paying a premium in exchange for financial protection.
insurance
which type of limit stipulates expense limits for individual items as opposed to a maximum total limit?
internal
the eligibility provision defines who:
is entitled to benefits under the policy
What is the day-in, day-out assistance that you might need if you ever have an illness or disability that lasts a long time and leaves you unable to care for yourself?
long-term care
comprehensive major medical insurance policies are complete insurance policies offering a very _____ deductible
low or small
______ medical expense insurance pays most of the costs exceeding those covered by the hospital, surgical, and physician expense policies.
major
which type of insurance pays the larger expenses of a serious injury or long illness, including those covered by the hospital, surgical, and physician expense policies?
major medical expense insurance
prepaid health plans that provide comprehensive health care to members are called _________.
managed care
basic health services for an HMO include inpatient and outpatient services such as ___________.
mental health emergency care substance abuse
The Health Insurance Portability Act of 1996 provides:
new standards so workers would not lose health insurance if they change jobs a parent with a sick child can move form one health plan to another without paying more for coverage than other employees do.
a good health insurance policy provides which of the following?
offer basic coverage for hospital & doctor bills provide at least 120 days' hospital room and board in full provide at least $1 million lifetime max for each family member pay at least 80% for out-of-hospital expenses after a yearly deductible of $1,000 per person or $2,000 per family impose no unreasonable exclusions limit your out-of-pocket expenses to no more than $4,000 to $6,000 a year, excluding dental, optical, and prescription costs A stop-loss provision so the policyholder will pay no more than $6,000 out of pocket a year
coordination of benefits (COB) is a method of integrating the benefits payable under more than _______ health insurance plan.
one or 1
surgical expense insurance pays part or all of surgeons' fees for a(n)______.
operation, procedure, or surgery
self- insurance is an arrangement in which a company collects premiums from employees and _____.
pays medical benefits as needed
which type of insurance provides benefits for doctors' fees for nonsurgical care, X-rays, and Lab tests?
physician expense insurance
a network of selected contracted participating providers, also called an HMO-PPO hybrid, is a :
point-of-service plan
a preferred provider organization (PPO) is a group of doctors and hospitals that agree to provide health care to members at ___________ fees that are slightly higher than those for health maintenance organizations.
prearranged, predetermined, set, fixed, given, approved, flat, or negotiated
Similar to car and life insurance, the individual pays a specified _________ for health insurance in exchange for some degree of financial assurance.
premium, fee, amount, or rate
managed care refers to ________ health plans that provide comprehensive health care to members.
prepaid
flexible spending accounts allow you to contribute ______ dollars to an account managed by your employer.
pretax
Dental expense insurance provides reimbursement for the expense of services and supplies and encourages ________ dental care.
preventive, routine, or good
Health insurance provides _______ to alleviate the financial burden individuals suffer from illness or injury.
protection
a point-of-service plan is a network of selected contracted participating _________.
providers, doctors, or physicians
to establish _______ and benefits, insurance company actuaries rely on statistics that tell them how many people in a certain population group will become ill and how much their illness will cost
rates
which policy provides benefits based on the actual expense incurred?
reimbursement
The first thing you should do if your health coverage claim has been denied is to:
review your policy and explanation of benefits
the first thing you should do if your health coverage claim has been denied is to:
review your policy and explanation of benefits.
the reasons for the increased need for home health care include ________.
rising hospital costs older U.S. population New medical technology
Hospital expense insurance pays part or all of hospital bills for ______, board, and other charges.
room
the main risk involved with a _______ health plan is the financial burden if the medical bills are greater than the amount covered by premium income.
self-funded
which type of insurance pays part or all of the surgeon's fees for an operation?
surgical expense insurance
which of the following is not true about hospital expense coverage?
these policies pay all costs of being hospitalized with no limits
health insurance is one way people protect themselves against economic losses due to illness, accident, or disability.
true
physician expense insurance provides benefits for which of the following?
x-rays lab tests doctors' fees for nonsurgical care
the money in a flexible spending account must be used for health care and used by the end of the ______.
year
