Medical Expense Insurance

M has a Major Medical insurance policy with a $200 flat deductible and an 80% Coinsurance clause. If M incurs a $2,200 claim for an eligible medical expense, how much will M receive in payment for this claim?

$1,600 In this situation, $2,200 - $200 deductible x 80% = $1,600.

An individual has a Major Medical policy with a $5,000 deductible and an 80/20 Coinsurance clause. How much will the INSURED have to pay if a total of $15,000 in covered medical expenses are incurred?

$7,000

Which of the following costs would a Basic Hospital/Surgical policy likely cover?

Surgically removing a facial birthmark

A Hospital/Surgical Expense policy was purchased for a family of four in March of 2013. The policy was issued with a $500 deductible and a limit of four deductibles per calendar year. Two claims were paid in September 2013, each incurring medical expenses in excess of the deductible. Two additional claims were filed in 2014, each in excess of the deductible amount as well. What would be this family's out-of-pocket medical expenses for 2013?

$1,000

Which of the following statements about Health Reimbursement Arrangements (HRA) is CORRECT?

If the employee paid for qualified medical expenses, the reimbursements may be tax-free

In order to establish a Health Reimbursement Arrangement (HRA), it MUST

be established by the employer

A Health Reimbursement Arrangement MUST be established

by the employer

All of the following statements about Major Medical benefits are true EXCEPT The deductible can be expressed as a fixed dollar amount The benefit period begins only after a specified amount of expenses have accrued Benefits are generally expressed as a percentage of eligible expenses Benefits have no maximum limit

Benefits have no maximum limit

A characteristic of Preferred Provider Organizations (PPOs) would be:

Discounted fees for the patient

Which of the following statements BEST describes the intent of a Coinsurance clause in a Major Medical policy?

Discourages overutilization of the insurance coverage

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

Dread disease insurance

S wants to open a tax-exempt Health Savings Account. To qualify for this type of account, Federal law dictates that S must be enrolled in a

High-deductible health plan

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?

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

Which of the following situations does a Critical Illness plan cover? Asthma Leukemia Alcohol rehabilitation Severe car accident

Leukemia

In Major Medical Expense policies, what is the intent of a Stop Loss provision?

Limits an insured's out-of-pocket medical expenses

Which of these options can an individual use their medical flexible spending account to pay for?

Prescription drugs

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

Usual, customary, and reasonable expenses

Major Medical policies typically

contain a deductible and coinsurance

A prospective insured completes and signs an application for health insurance but intentionally conceals information about a pre-existing heart condition. The company issues the policy. Two months later, the insured suffers a heart attack and submits a claim. While processing the claim, the company discovers the pre-existing condition. In this situation, the company will

continue coverage but exclude the heart condition

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 terms of the policy

Basic Medical Expense insurance

has lower benefit limits than Major Medical insurance

With a Basic Medical Expense policy, what does the hospitalization expense cover?

hospital room and board

The first portion of a covered Major Medical insurance expense that the insured is required to pay is called the

initial deductible

Which of the following services is NOT covered under a hospitalization expense policy? daily room and board surgeon's fees intensive care miscellaneous expenses

surgeon's fees

Which of the following is NOT a limited benefit plan? cancer policies life insurance policies dental policies critical illness policies

life insurance policies

A major medical policy typically

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

Which of the following policy features allows an insured to defer current health charges to the following year's deductible instead of the current year's deducitble?

Carryover provision

N has a Major Medical policy that only pays a portion of N's medical expenses. N is responsible for paying the remaining balance. This provision is known as

Coinsurance

Which of the following health insurance coverages is BEST suited for meeting the expenses of catastrophic illness?

Major Medical

Which of the following individual health insurance policies will provide the broadest protection?

Major Medical

Which of the following types of health coverage frequently uses a deductible?

Major Medical policy

Comprehensive Major Medical policies usually combine

Major Medical with Basic Hospital/Surgical coverage

Deductibles are used in health policies to lower

overuse of medical services

Basic Hospital and Surgical policy benefits are

lower than the actual expenses incurred

Which of the following BEST desscribes a Hospital Indemnity policy?

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

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?

$2,100

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?

$3,000

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

$3,600

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?

$720 In this situation, $400 deductible + 20% of the remaining medical bill = $720.

Which of these is NOT a characteristic of a Health Reimbursement Arrangement (HRA)? Employee funds the HRA entirely Employer funds the HRA entirely HRA's can be offered with other health plans HRA's allow reimbursement for eligible medical expenses

Employee funds the HRA entirely

For which of the following expenses does a Basic Hospital policy pay?

Hospital room and board

Which of the following statements BEST describes dental care indemnity coverage?

Services are reimbursed after insurer receives the invoice

Which of the following statements BEST defines usual, customary, and reasonable (UCR) charges?

The maximum amount considered eligible for reimbursement by an insurance company under a health plan

A comprehensive 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 hospital charges physician fees experimental and investigative services nursing services

experimental and investigative services

The phrase "This policy will only pay for a semi-private room" is an example of a(n)

internal limit