Ch 3 Health Exam - Medical Expense Insurance Flashcards by catherine alzate (2024)

J was reviewing her Health Insurance policy and noticed the phrase “This policy will only pay for a semi-private room”. This phrase is considered to be a(n):

A. hidden deductible
B. Internal limit
C. Restricted provision
D. Stop loss

Which of the following medical expenses does Cancer insurance NOT cover?

A. Chemotherapy
B. Radiation treatment
C. Physical visit
D. Arthritis

All of the following statements about Major Medical benefits are true, EXCEPT:

A. The deductible can be expressed as a fixed dollar amount
B. The benefit period begins only after a specified amount of expenses have accrued
C. Benefits are generally expressed as a percentage of eligible expenses
D. Benefits have no maximum limit

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

A. Surgically removing a facial birthmark
B. Care is given at a nursing home
C. Treating a wound from a soldier injured at war
D. Lost income caused by a hospital stay

Which provision allows a portion of any used medical benefits to be restored following a particular amount of benefit has been used, or after the policy has been in effect for a particular period of time?

A. Reimbursem*nt benefits
B. Restoration of unused benefit
C. Restoration of used benefit
D. Medical offset the benefit

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

A. MEWA
B. Blanket Insurance
C. Dread disease insurance
D. Disability insurance

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

A. Major Medical policy
B. Basic Surgical policy
C. Basic Hospital policy
D. Worker’s Compensation

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

A. Hospital room and board
B. Prescription medication
C. Surgical fees
D. Physicians fees

C was injured while deep sea diving and requires a hospital stay. C has a Major Medical policy with an 80/20 coinsurance and a $400 deductible. What is the MAXIMUM C will pay if the covered medical expenses are $2000?

A. $0
B. $400
C. $720
D. $1000

This type of deductible provision states that should more than one family member be involved in a common accident, or suffer the same illness, only one individual deductible amount shall be applied.

A. Individual deductible
B. Corridor deductible
C. Family maximum deductible
D. Common accident deductible

In order to establish a Health Reimbursem*nt Arrangement (HRA), it MUST:

A. Be offered in conjunction with other employer-provided health benefits
B. Limit the benefits to prescription drugs only
C. Be established by the employer
D. Limit the amount of money the employee can contribute toward the account

Basic Medical Expense Insurance:

A. Normally has a deductible and coinsurance
B. Covers an illness but not an accident
C. Has lower benefit limits than Major Medical Insurance

A Health Reimbursem*nt Arrangement MUST be established:

A. With employee funding
B. With other employer-sponsored benefit plans
C. By the employer
D. Only during specific open enrollment periods

Which of the following situations does a Critical illness plan cover?

A. Asthma
B. Leukemia
C. Alcohol rehabilitation
D. Severe car accident

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

A. The maximum premium an insurer can charge for their health insurance based on geography
B. The maximum amount an employer can contribute to a contributory health plan
C. The maximum deductible an insured can be charged
D. The maximum amount considered eligible for reimbursem*nt by an insurance company under a health plan

M is insured under a basic Hospital/Surgical Expense policy. A physician performs surgery on M. What determines the claim M is eligible for?

A. Claim payment is equal to the physician’s actual charges
B. Claim payment is negotiated between the physician and patient
C. Determined by the schedule of benefits from the hospital
D. Determined by the terms of the policy

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

A. Deductible
B. Coinsurance
C. Usual, customary, and reasonable expense
D. Hospital expense

Which of the following BEST describes a Hospital Indemnity policy?

A. Coverage that reimburses an insured for surgeon expenses
B. Coverage that pays a stated amount per day of a covered hospitalization
C. Coverage that replaces lost income due to hospitalization
D. Coverage that pays for hospital room and board

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

A. Corridor deductible
B. Initial deductible
C. Stop-loss deductible
D. Coinsurance deductible

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 deductible?

A. Deferral provision
B. Carryover provision
C. Stop Loss provision
D. Corridor provision

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:

A. Low-deductible health plan
B. Medicare Supplement
C. High-deductible health plan
D. Flexible savings plan

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

A. Services are reimbursed before the insurer receives the invoice
B. Services are reimbursed after the insurer receives the invoice.
C. In-network dentists must always be used
D. Very limited list of providers

A characteristic of Preferred Provider Organizations (PPO’s) would be:

A. Discounted fees for the patient
B. Not allowed to see out-of-network physicians
C. Physicians are paid on a capitation basis
D. A primary care physician is required

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?

A. 0
B. $3,000
C. $8,000
D. $11,000

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 suffered a heart attack and submits a claim. While processing the claim, the company discovers the pre-existing condition. In this situation, the company will:

A. Continue coverage but request a corrected application
B. Deny coverage and increase premiums
C. Continue coverage but exclude the heart condition
D. Rescind the coverage and return the premiums

Comprehensive Major Medical policies usually combine:

A. Major Medical with Disability Income coverage
B. Major Medical with Basic Hospital/Surgical coverage
C. Basic Hospital/Surgical with Accidental coverage
D. Basic/Hospital/Surgical with Disability Income coverage

B’s policy provides coverage on an in-hospital basis only and contains a limited daily room and board benefit. Which of these policies does B have?

A. Comprehensive Major Medical
B. Basic Hospital
C. Critical illness
D. Basic Surgical

Deductibles are used in health policies to lower:

A. The incidents of fraud
B. The coinsurance amount
C. Overuse of medical services
D. Adverse selection

A catastrophic illness would be best covered by which of the following health insurance plans?

A. Major Medical
B. Limited
C. Indemnity
D. Surgical Expense

The individual Health Insurance policy that offers the broadest protection is a(n) ____ ____.

A. Surgical Benefit
B. Indemnity Medical
C. Major Medical
D. Hospital Expense

Basic Hospital and Surgical policy benefits are:

A. Lower than the actual expenses incurred
B. Higher than the actual expenses incurred
C. Normally subject to deductibles
D. Normally subject to coinsurance

Generally, how long is the benefit period for a Major Medical Expense Plan?

A. One year
B. Two years
C. Three years
D. Four years

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

A. Limits an insurer’s premium increases
B. Limits an insurer’s liability
C. Limits an insured’s out-of-pocket medical expenses
D. Limits an insurer’s coverage for pre-existing conditions

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?

A. $2,000
B. $1,760
C. $1,600
D. $400

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?

A. $2,100
B. $2,020
C. $2,000
D. $100

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

A. Vitamins and supplements
B. Prescription drugs
C. Household expenditures
D. Cosmetic procedures

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

A. Discourages overutilization of insurance coverage
B. Minimizes the need for deductibles
C. Discourages adverse selection
D. Minimizes the waiting period

Major Medical policies typically:

A. Pay 100% of covered expenses
B. Contain a deductible and coinsurance
C. Require us of in-network facilities only
D. Do does not contain a deductible and coinsurance

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?

A. $500
B. $1,000
C. $1,500
D. $2,000

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?

A. $1,600
B. $2,000
C. $3,600
D. $8,000

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 healthcare services are typically covered EXCEPT for:

A. Hospital charges
B. Physician fees
C. Experimental and investigative services
D. Nursing services