CHAPTER 4 HEALTH INSURANCE
a disease Diseases are usually covered by fee for service health insurance plans.
A fee for service health insurance plan will normally cover
preventative health services Preventative health services are normally covered under a health insurance policy.
A health insurance policy will typically cover
fee-for-service
A payment system for health care in which the provider is paid for each service given is called
fee-for-service A fee-for-service payment system is one where the provider is paid for each service given.
A payment system for health care in which the provider is paid for each service given is called
$140 Because the insured has previously met her deductible, the eligible expenses for a claim is the entire $175. The insurance company pays 80% of $175, or $140.
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?
indicates a preexisting condition In this situation, the treatment indicates a preexisting condition.
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
$900 In this situation, the group insurance carrier will pay 90% of the covered loss after the deductible has been applied.
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?
benefit schedule Benefit schedules set pre-determined limits or maximums on how much money an insured can be reimbursed for a covered loss.
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
$5,000
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?
With 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.
How is a health provider reimbursed if they do NOT have an agreement in place with the insurance company?
$700 In this situation, the insured will pay $500 deductible plus $200 coinsurance = $700.
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?
an injury occurring at the insured's residence An injury occurring at the insured's residence would be covered under Medical Expense Insurance.
Medical Expense Insurance would cover
the specified number of days an insured must wait before becoming eligible to receive benefits for each hospitalization In a hospital indemnity plan, an elimination period refers to the number of days an insured must wait before becoming eligible to receive benefits for each hospital stay.
The elimination period under a hospital indemnity plan is
medical and hospitalization expenses The focus of major medical insurance is providing coverage for medical and hospitalization expenses.
The focus of major medical insurance is providing coverage for
Dread disease insurance Dread disease insurance provides benefits for ONLY specific types of illnesses such as cancer or stroke.
What type of policy would only provide coverage for specific types of illnesses (cancer, stroke, etc)?
No deductible payment is required A health insurance plan with first dollar coverage means no deductible payment is required before expenses are reimbursed.
When an insured has a major medical plan with first dollar coverage, how does this impact the benefits paid?
Integrated deductible A single deductible applied to both medical and dental insurance coverage is referred to as an integrated deductible.
Which of the following types of deductibles would apply a single deductible to both medical and dental insurance coverage?
