Ch 13: Medical Expense Insurance

Question 1

In the usual, customary, and reasonable (UCR) approach, the insurer will pay based on the amount physicians in the same ___________ are normally charged for the same or similar procedure.

Answer 1

Geographical area

Question 2

What are the two kinds of major medical expenses?

Answer 2

Comprehensive major medical and supplemental major medical expense.

Question 3

What happens in a comprehensive major medical?

Answer 3

This plan essentially covers all medical expenses under one policy. This type of policy has a deductible.

Question 4

A provision stating that persons with health insurance and their companies share covered losses in a agreed proportion

Answer 4

Coinsurance

Question 5

Stop loss limit is?

Answer 5

Same as out of pocket max

Question 6

What is supplemental major medical?

Answer 6

A combo of a basic policy and a major medical policy

Question 7

What does the following limited policy do: hospital confinement indemnity policies/hospital income

Answer 7

Pays a states dollar amount each day the insured is confined to a hospital

Question 8

What does the following limited policy do:

Dread disease/specified disease

Answer 8

A plan covering hospital confinement to treat cancer

Question 9

ACA required insurers to offer ________ care for children

Answer 9

Vision

Question 10

Under women’s health and cancer act (WHCRA)..

Answer 10

Reconstruction of the. Rest on which the. Mastectomy was performed is covered

Question 11

What’s the yearly out of pocket max for 2015-17 for an ind under PPACA

Answer 11

2015 6000
2016 6850
2017 7150

Question 12

Under medical loss ratio (MLR), the percent of premium dollars collected by insurers must be spent on?

Answer 12

Medical benefits & quality improvement

Question 13

For large employer plans, the MLR must be at least?

Answer 13

85%

Question 14

For small employer plans and individual plans, MLR must be?

Answer 14

80%

Question 15

What if insurers do not meet the MLR?

Answer 15

Insurers must refund excess premiums for all plans in that market segment

Question 16

To remain a certified agent with covered California, the agent must be certified every how many years?

Answer 16

5

Question 17

In the metal tier prob, bronze plan is:

Answer 17

Lowest premium, hightesy out of pocket expenses

Question 18

What’s the actuarial value (coin insurance) for the bronze plan?

Answer 18

60% – company paid 60% of the bill

Question 19

The actuarial value of a silver plan

Answer 19

70%

Question 20

Actuarial value of a platinum plan?

Answer 20

90%

Highest premium, lowest out of pocket expense

Question 21

What’s the access for infants and mothers program?

Answer 21

Private health plan with Maternity only deductible or co payment greater than $500