Medical Expense Insurance Exam Review

Questions and Answers

Which of the following services is NOT covered under a hospitalization expense policy?

Miscellaneous expenses

Surgeon's fees (correct)

Intensive care

Daily room and board

What services are covered under a hospitalization expense policy?

Daily room and board, intensive care, miscellaneous expenses

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?

Routine check-ups

Inpatient hospitalization

Emergency services

Experimental and investigative services (correct)

Basic Medical Expense insurance has what compared to Major Medical Insurance?

Lower benefit limits Signup and view all the answers

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

$1,600 Signup and view all the answers

What BEST describes a Hospital Indemnity policy?

Coverage that pays a stated amount per day of a covered hospitalization Signup and view all the answers

Deductibles are used in health policies to lower what?

Overuse of medical services Signup and view all the answers

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

$720 Signup and view all the answers

What does a major medical policy typically provide?

Benefits for reasonable and necessary medical expenses, subject to policy limits Signup and view all the answers

What determines the claim M is eligible for under a basic Hospital/Surgical Expense policy?

The terms of the policy Signup and view all the answers

Which statement BEST describes dental care indemnity coverage?

Dental care indemnity plans reimburse services only after the carrier receives the bill Signup and view all the answers

Which of the following is NOT a limited benefit plan?

Life insurance policy Signup and view all the answers

What are some examples of limited benefit plans?

Cancer policies, dental policies, critical illness policies Signup and view all the answers

Which types of health coverage frequently use a deductible?

Major Medical Policy Signup and view all the answers

What phrase refers to the fees charged by a healthcare professional?

Usual, customary, and reasonable expenses Signup and view all the answers

Which of these is NOT a characteristic of a Health Reimbursement Arrangement (HRA)?

Employee funds the HRA entirely Signup and view all the answers

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

Benefits have no maximum limit Signup and view all the answers

A Health Reimbursement Arrangement MUST be established by whom?

The employer Signup and view all the answers

Comprehensive Major Medical policies usually combine what?

Basic Hospital/Surgical and Major Medical insurance Signup and view all the answers

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

Hospital room and board Signup and view all the answers

The phrase 'This policy will only pay for a semi-private room' is an example of what?

Internal limit Signup and view all the answers

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

Initial deductible Signup and view all the answers

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

Limits an insured's out-of-pocket medical expenses Signup and view all the answers

If J's Major Medical policy has a $2,000 deductible and an 80/20 Coinsurance clause with a bill for $10,000, how much would J pay?

$3,600 Signup and view all the answers

Study Notes

Hospitalization Expense Policy

Services NOT covered include surgeon's fees.
Covered services include daily room and board, intensive care, and miscellaneous expenses.

Comprehensive Major Medical Policy

Identifies Eligible Expenses for covered health care services.
Typically covers necessary services, excluding experimental and investigative services.

Basic Medical Expense Insurance

Provides lower benefit limits compared to Major Medical Insurance.

Major Medical Insurance Claims

With a $200 deductible and 80% coinsurance, a $2,200 claim results in a payment of $1,600.
A policy typically covers reasonable and necessary medical expenses under specified limits.

Hospital Indemnity Policy

Pays a set amount per day for hospitalization.

Deductibles in Health Policies

Serve primarily to reduce overuse of medical services.

Medical Expense Calculation

In a 80/20 coinsurance policy, the maximum a patient can pay is calculated by adding the deductible to 20% of the remaining bill. A $2,000 expense with a $400 deductible results in a maximum payment of $720.

Claims Eligibility

Under basic hospital/surgical expense policies, claims are based on policy terms.

Dental Care Indemnity Coverage

Reimbursement for services occurs only after the insurer receives the provider's bill.

Limited Benefit Plans

Examples include cancer policies, dental policies, and critical illness policies. Life insurance is NOT considered a limited benefit plan.

Usual, Customary, and Reasonable Expenses

Refers to the fees charged by healthcare providers.

Health Reimbursement Arrangement (HRA)

Must be established by the employer and is not funded by employees.

Major Medical Benefits

Generally includes a maximum limit on benefits.

Comprehensive Major Medical Policies

Combine Basic Hospital/Surgical Insurances with Major Medical Insurance.

Basic Medical Expense Coverage

Covers costs for hospital room and board.

Internal Limit Example

A phrase like "This policy will only pay for a semi-private room" exemplifies an internal limit.

Major Medical Insurance Components

The initial deductible is the first portion of an expense the insured pays.

Stop Loss Provision

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

Major Medical Claims Calculation

A $2,000 deductible and 80/20 coinsurance on a $10,000 bill results in a payment of $3,600 by the insured.

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Description

Test your knowledge with this flashcard quiz on medical expense insurance. Focus on what services are covered under hospitalization policies and major medical health insurance provisions. Perfect for exam preparation in healthcare finance.