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Questions and Answers
Who is the individual paid on a fee-for-service basis?
Who is the individual paid on a fee-for-service basis?
- Subscriber
- Administrator
- Insured
- Provider (correct)
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:
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:
- Out of pocket provision
- Stop-loss provision
- Copayment
- Deductible (correct)
"Maximum benefits" refers to the:
"Maximum benefits" refers to the:
- Upper limits of what an insurance company will pay for any particular claim
- Upper limits of what the insured will pay in out-of-pocket expenses
- Upper limit of the total lifetime benefits the insurance company will pay (correct)
- Upper limit percentage of what the insurance company will pay for coinsurance
Medical Expense Insurance would cover:
Medical Expense Insurance would cover:
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?
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?
How is a health provider reimbursed if they do NOT have an agreement in place with the insurance company?
How is a health provider reimbursed if they do NOT have an agreement in place with the insurance company?
The elimination period under a hospital indemnity plan is:
The elimination period under a hospital indemnity plan is:
Kate has a Major Medical Plan with a 75/25 coinsurance and a deductible of $25. How much will she have to pay if she, not having met any of her deductible, visits the doctor and receives a bill for $125?
Kate has a Major Medical Plan with a 75/25 coinsurance and a deductible of $25. How much will she have to pay if she, not having met any of her deductible, visits the doctor and receives a bill for $125?
Low frequency diseases can be exclusively covered by what kind of health insurance policies?
Low frequency diseases can be exclusively covered by what kind of health insurance policies?
A dread disease policy is considered to be a type of:
A dread disease policy is considered to be a type of:
A fee-for-service health insurance plan will normally cover:
A fee-for-service health insurance plan will normally cover:
Which of the following is NOT included under a health benefit plan?
Which of the following is NOT included under a health benefit plan?
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?
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?
All of the following are qualifications for establishing a health savings account (HSA) EXCEPT:
All of the following are qualifications for establishing a health savings account (HSA) EXCEPT:
All of the following plans allow for employee contributions to be taken on a pre-tax basis EXCEPT:
All of the following plans allow for employee contributions to be taken on a pre-tax basis EXCEPT:
When an insured has a major medical plan with first dollar coverage, how does this impact the benefits paid?
When an insured has a major medical plan with first dollar coverage, how does this impact the benefits paid?
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Study Notes
Medical Expense Insurance Concepts
- Provider: Individual paid on a fee-for-service basis in medical insurance.
- Deductible: A specific out-of-pocket amount that must be paid before insurance benefits are activated; important to understand annual health policy requirements.
- Maximum Benefits: Refers to the upper limit of total lifetime benefits an insurance company will pay, crucial for determining policy effectiveness.
Coverage and Claims
- Medical Expense Insurance generally covers injuries occurring at the insured's residence, excluding events like war or elective surgeries.
- Understanding how coverage works with deductibles and coinsurance is essential; for instance, an insured with a $500 deductible and 90% coinsurance who incurs $1,500 in expenses pays only $900 after calculations.
Reimbursement Guidelines
- Health providers without agreements with insurance companies are reimbursed based on usual, customary, and reasonable fees, highlighting the importance of provider agreements.
- Elimination Period in hospital indemnity plans indicates a required waiting time after policy issuance before benefits become available for hospitalization.
Coinsurance and Payments
- In a scenario with a 75/25 coinsurance and a $25 deductible, a doctor visit with a $125 bill leads to a $50 out-of-pocket cost for the insured, illustrating the impact of deductibles and coinsurance.
- Major Medical expense plans operate on an 80/20 coinsurance basis; an insured filing a $1,000 claim is responsible for $200, indicating the insurer pays 80% of the claim.
Special Policy Types
- Limited health insurance policies specifically cover low-frequency diseases, while dread disease policies also fall under this category, emphasizing coverage limitations.
- Different health benefit plans include major medical, basic hospital, and surgical expense policies, but hospital indemnity plans are not considered traditional health benefit plans.
Health Savings Accounts (HSA)
- Qualifications for establishing an HSA generally include being enrolled in a high deductible health plan and not being over 65 years or enrolled in Medicare, but being in a plan with a prescription drug benefit is not a requirement.
Employee Contribution Plans
- Employee contributions can be pre-tax under several plans like Section 125 Plans and Cafeteria Plans, but contributions under Health Reimbursement Arrangements do not have this benefit.
First Dollar Coverage
- Major medical plans with first dollar coverage do not require any deductible payment, meaning the insured can access benefits immediately without initial out-of-pocket costs.
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