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Questions and Answers
In Major Medical Expense policies, what is the intent of a Stop Loss provision?
In Major Medical Expense policies, what is the intent of a Stop Loss provision?
Which of the following costs would a Basic Hospital/Surgical policy likely cover?
Which of the following costs would a Basic Hospital/Surgical policy likely cover?
How much will Q be responsible for paying on a claim if hospitalized for 3 days with a bill of $10,100 and a Major Medical policy that has a $100 deductible and 80/20 coinsurance?
How much will Q be responsible for paying on a claim if hospitalized for 3 days with a bill of $10,100 and a Major Medical policy that has a $100 deductible and 80/20 coinsurance?
$2,100
For which of the following expenses does a Basic Hospital policy pay?
For which of the following expenses does a Basic Hospital policy pay?
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In order to establish a Health Reimbursement Arrangement (HRA), it MUST
In order to establish a Health Reimbursement Arrangement (HRA), it MUST
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Which of the following situations does a Critical Illness plan cover?
Which of the following situations does a Critical Illness plan cover?
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Basic Hospital and Surgical policy benefits are
Basic Hospital and Surgical policy benefits are
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Which of these options can an individual use their medical flexible spending account to pay for?
Which of these options can an individual use their medical flexible spending account to pay for?
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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
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
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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?
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?
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Which of the following BEST describes a Hospital Indemnity policy?
Which of the following BEST describes a Hospital Indemnity policy?
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How much will the insured be responsible to pay with $11,000 in covered medical expenses under a group Major Medical plan with 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 under a group Major Medical plan with a $1,000 deductible and an 80/20 coinsurance clause?
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Which of the following statements BEST describes the intent of a Coinsurance clause in a Major Medical policy?
Which of the following statements BEST describes the intent of a Coinsurance clause in a Major Medical policy?
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Deductibles are used in health policies to lower
Deductibles are used in health policies to lower
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Which of the following health insurance coverages is BEST suited for meeting the expenses of catastrophic illness?
Which of the following health insurance coverages is BEST suited for meeting the expenses of catastrophic illness?
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What would be this family's out-of-pocket medical expenses for 2013 if they have a Hospital/Surgical Expense policy with a $500 deductible and a limit of four deductibles per calendar year?
What would be this family's out-of-pocket medical expenses for 2013 if they have a Hospital/Surgical Expense policy with a $500 deductible and a limit of four deductibles per calendar year?
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Which of the following phrases refers to the fees charged by a healthcare professional?
Which of the following phrases refers to the fees charged by a healthcare professional?
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Which of the following types of health coverage frequently uses a deductible?
Which of the following types of health coverage frequently uses a deductible?
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Which of the following individual health insurance policies will provide the broadest protection?
Which of the following individual health insurance policies will provide the broadest protection?
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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
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
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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
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
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What is the MAXIMUM C will pay if the covered medical expenses are $2,000 with an 80/20 coinsurance clause and a $400 deductible?
What is the MAXIMUM C will pay if the covered medical expenses are $2,000 with an 80/20 coinsurance clause and a $400 deductible?
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Which of the following statements about Health Reimbursement Arrangements (HRA) is CORRECT?
Which of the following statements about Health Reimbursement Arrangements (HRA) is CORRECT?
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With a Basic Medical Expense policy, what does the hospitalization expense cover?
With a Basic Medical Expense policy, what does the hospitalization expense cover?
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Which of these is NOT a characteristic of a Health Reimbursement Arrangement (HRA)?
Which of these is NOT a characteristic of a Health Reimbursement Arrangement (HRA)?
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Which of the following is NOT a limited benefit plan?
Which of the following is NOT a limited benefit plan?
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Which of the following services is NOT covered under a hospitalization expense policy?
Which of the following services is NOT covered under a hospitalization expense policy?
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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
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
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If J's Major Medical policy has a $2,000 deductible and an 80/20 Coinsurance clause, how much would J pay if hospitalized and receives a bill for $10,000?
If J's Major Medical policy has a $2,000 deductible and an 80/20 Coinsurance clause, how much would J pay if hospitalized and receives a bill for $10,000?
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What type of policy would only provide coverage for specific types of illnesses (cancer, stroke, etc)?
What type of policy would only provide coverage for specific types of illnesses (cancer, stroke, etc)?
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How much will the insured have to pay if a Major Medical policy has a $5,000 deductible and an 80/20 Coinsurance clause, with a total of $15,000 in covered medical expenses incurred?
How much will the insured have to pay if a Major Medical policy has a $5,000 deductible and an 80/20 Coinsurance clause, with a total of $15,000 in covered medical expenses incurred?
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Which of the following statements BEST defines usual, customary, and reasonable (UCR) charges?
Which of the following statements BEST defines usual, customary, and reasonable (UCR) charges?
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M is insured under a basic Hospital/Surgical Expense policy. A physician performs surgery on M. What determines the claim M is eligible for?
M is insured under a basic Hospital/Surgical Expense policy. A physician performs surgery on M. What determines the claim M is eligible for?
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Basic Medical Expense insurance
Basic Medical Expense insurance
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Which of the following medical expenses does Cancer insurance NOT cover?
Which of the following medical expenses does Cancer insurance NOT cover?
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Comprehensive Major Medical policies usually combine
Comprehensive Major Medical policies usually combine
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The first portion of a covered Major Medical insurance expense that the insured is required to pay is called the
The first portion of a covered Major Medical insurance expense that the insured is required to pay is called the
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A Health Reimbursement Arrangement MUST be established
A Health Reimbursement Arrangement MUST be established
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The phrase 'This policy will only pay for a semi-private room' is an example of a(n)
The phrase 'This policy will only pay for a semi-private room' is an example of a(n)
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All of the following are limited benefit plans EXCEPT
All of the following are limited benefit plans EXCEPT
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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?
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?
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Major Medical policies typically
Major Medical policies typically
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A characteristic of Preferred Provider Organizations (PPOs) would be:
A characteristic of Preferred Provider Organizations (PPOs) would be:
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All of the following statements about Major Medical benefits are true EXCEPT
All of the following statements about Major Medical benefits are true EXCEPT
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A major medical policy typically
A major medical policy typically
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If M has a Major Medical insurance policy with a $200 flat deductible and an 80% Coinsurance clause, how much will M receive in payment for a $2,200 claim for an eligible medical expense?
If M has a Major Medical insurance policy with a $200 flat deductible and an 80% Coinsurance clause, how much will M receive in payment for a $2,200 claim for an eligible medical expense?
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Which of the following statements BEST describes dental care indemnity coverage?
Which of the following statements BEST describes dental care indemnity coverage?
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Study Notes
Major Medical Expense Insurance Key Concepts
- Stop Loss Provision: Limits an insured's out-of-pocket medical expenses, protecting them financially.
- Basic Hospital/Surgical Coverage: Typically covers surgical procedures like removing facial birthmarks but may not cover care given in nursing homes or lost wages.
- Claims and Payments: Hospitalized individuals need to understand deductible and coinsurance calculations to determine personal responsibility. For example, a $10,100 bill with an 80/20 coinsurance and $100 deductible results in a $2,100 payment by the insured.
- Coverage Types: Basic Hospital policies generally cover hospital room and board, while major medical policies cover a broader range of health expenses.
Health Reimbursement Arrangements (HRA)
- An HRA must be established by the employer and often comes along with other health benefits. It allows for tax-free reimbursements for qualified medical expenses.
- An HRA lacks employee contributions; it is fully funded by the employer.
Coinsurance and Deductibles
- Coinsurance clauses in major medical policies discourage overutilization by requiring insureds to share in medical costs.
- Deductibles serve to reduce overuse of services by making insureds accountable for initial expenses before insurance payments kick in.
Types of Health Insurance
- Major Medical Insurance: Provides extensive coverage for medical expenses and typically includes deductible and coinsurance factors.
- Dread Disease Insurance: Covers specific illnesses exclusively, such as cancer or stroke.
Important Policy Features
- Usual, Customary, and Reasonable Charges (UCR): Refers to the maximum amount an insurer will consider for reimbursement for a provided medical service.
- Internal Limit: Refers to certain policy stipulations like coverage for semi-private rooms within hospitalization expense policies.
- Hospital Indemnity Policy: Provides a per-day benefit during hospitalization, regardless of incurred expenses.
Exclusions and Limitations
- Certain policies will not cover pre-existing conditions for a defined period, and specific expenses (e.g., arthritis) may not fall under designated coverage, such as cancer policies.
Payment Calculations
- Examples demonstrate how to calculate insurer payments based on deductibles. For instance, with an $11,000 medical expense and an $1,000 deductible, the insured pays $3,000 after coinsurance calculations.
Additional Coverage Characteristics
- Dental care indemnity coverage functions with reimbursement after service completion, emphasizing accuracy in billing and service delivery.
Specialty Coverages
- Policies like critical illness plans specifically cater to serious conditions such as leukemia, emphasizing the targeted nature of such plans compared to broader coverage options.
Conclusion
- Understanding the various types of medical insurance, their definitions, and how they function—including terms like coinsurance, deductibles, HRAs, and specific coverage—enables individuals to make informed insurance decisions and manage their healthcare expenses effectively.
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Description
Test your knowledge on key concepts related to Major Medical Expense policies and Basic Hospital/Surgical coverage. This set of flashcards covers important definitions and provisions that play a vital role in medical expense insurance. Improve your understanding and prepare effectively for your studies in this area.
