Lesson 4.4 Medical Expense Insurance

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 In this situation, the insured will pay $500 deductible plus $200 cosinsurance = $700.

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

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 In this situation, the insured will pay the stop-loss limit of $5,000.

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

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? $500 $900 $1,000 $1,350

$900 The group insurance carrier will pay 90% of the covered loss after the deductible has been applied.

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

The focus of major medical insurance is providing coverage for critical illnesses only preventive care medical and hospitalization expenses doctor's visits

medical and hospitalization expenses

Who is the individual paid on a fee-for-service basis? subscriber adminstrator insured provider

provider

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? $160 $200 $600 $800

$200

A fee for service health insurance plan will normally cover vitamins and natural remedies cosmetic procedures gym membership a disease

a disease

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

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 loss chart benefit summary benefit schedule coverage menu

benefit schedule

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

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

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 premium only plan cafeteria plan health reimbursement arrangement plan

health reimbursement arrangement plan

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

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 does not count as a preexisting condition is not required to be reported on the application indicates a preexisting condition is irrelevant to underwriting

indicates a preexisting condition

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

A dread disease policy is considered to be a type of hospital expense policy group health insurance policy major medical insurance policy limited health insurance policy

limited health insurance policy

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 percentage of the remaining covered loss is owed by the insured

no deductible payment is required

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

preventative health services

The elimination period under a hospital indemnity plan is the period in which pre-exisiting conditions are not taken into consideration the period in which all deductibles are eliminated the specified number of days after an insurance policy's issue date during which coverage is not afforded for sickness the specified number of days an insured must wait before becoming eligible to receive benefits for each hospitalization

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

"Maximum benefits" refers to the upper limit of the total lifetime benefits the insurance company will pay upper limit percentage of what the insurance company will pay for coinsurance upper limits of what the insured will pay in out-of-pocket expenses upper limits of what an insurance company will pay for any particular claim

upper limit of the total lifetime benefits the insurance company will pay

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

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 reconstructive breast surgery after a mastectomy removing excess fat from an insured's waistline surgery to correct a birth defect reconstructive surgery after suffering injuries from an automobile accident

removing excess fat from an insured's waistline