Health Insurance

Question 1

this is also called accident and sickness insurance and other times ____ and ____ insurance

Answer 1

Health insurance… accident and health

Question 2

at its beginning, the original purpose of health insurance was to indemnify (reimburse) insureds for ____

Answer 2

just risk type expenses

Question 3

the purpose of health insurance is to protect an insured agains the risk of financial loss he/she cannot individually afford caused by ___, ____, or _____

Answer 3

injury illness disability

Question 4

Indemnity means ____

Answer 4

reimbursement

Question 5

both the principle of _____ and ____ ____ prohibit the insurance company from reimbursing an insured for more than the actual amount of the loss

Answer 5

indemnity, insurable interest

Question 6

a provision that is included in some policies. it allows insurance companies to reduce benefits so that the insured will be paid no more than his/her actual loss. it prevents the insured from collecting under multiple policies more than his or her actual loss.

Answer 6

coordination of benefits provision

Question 7

a policy that includes a coordination of benefits provision

Answer 7

coordinating policy

Question 8

a policy that does not include a coordination of benefits provision

Answer 8

non coordinating policy

Question 9

basic principles of the affordable health care act (ACA)

a. ACA requires that all people under age __ who are in the US legally to have hospital/medical expense reimbursement insurance
b. ACA applies only to hospital/medical policies for people under __
c. it does not apply to disability income, hospital income, limited disease, accidental death and dismemberment, medicare supplement, medicare advantage or long term care policies

Answer 9

65

Question 10

expense reimbursement pay only the insured’s _____ hospital/medical expenses. expense reimbursement usually include a coordination of benefits provision

Answer 10

actual

Question 11

stated benefit (stated value) policies pay a ___ or ___ benefit (value) independent of and unrelated to actual hospital or medical charges.

• usually do not include a coordination of benefits provision
• usually non coordinating

Answer 11

stated or fixed

Question 12

benefits to which an insured is entitled under a coordinating expense reimbursement policy will ______ by benefits to which the insured is entitled under a non coordinating stated value policy

Answer 12

not be reduced

Question 13

benefits to which an insured is entitled under a non coordinating stated value policy will be ____ in addition to benefits to which the insured is entitled under coordinating expense reimbursement policies

Answer 13

paid

Question 14

a coordinating policy can coordinate only with another ___ policy

Answer 14

coordinating

Question 15

an individual’s group health insurance benefits through his or her employment will be their ___

Answer 15

primary coverage

Question 16

if an individual has a primary insurance and their spouse has coverage as well, it is known as ____ or ____ coverage

Answer 16

excess or secondary

Question 17

both individual and group hospital/medical expense reimbursement insurance policies usually exclude expenses covered by ____ _____ insurance

Answer 17

workers compensation

Question 18

Medical information bureau Report

is a _____ for medical information for insurance companies that belong to it

Answer 18

clearinghouse

Question 19

Tax treatment of health insurance premiums and benefits

1. premiums on individual hospital/medical expense policies can ____ be tax deducted
   a. it depends on whether the individual is self employed or employed by someone else
   b. it also depends on whether the individual itemizes on their tax return
2. premiums usually cannot be tax deducted (___)
3. there is usually no tax on the benefits (___)
4. premiums and policies paid by the employer can be tax deducted by the employer (____)
5. there is usually no tax on benefits on group health coverage (tax free)
6. there is usually tax on benefits on group disability coverage

Answer 19

sometimes
non qualified
tax free
tax qualified

Question 20

Private health insurance companies

a. primarily offer ___ and ___ plans. there were originally established to issue risk indemnity policies
b. private health plans cover primarily ___-type expenses
c. these typically have the ___ restrictions to where the insured can go for service

Answer 20

HMO, PPo
risk
fewest

Question 21

Service organizations

a. blue cross was originally established as a non-profit service organization to assure the payment of _____ charges. blue shield was originally established as a non profit service org to assure payment of ___ charges
b. the covered member, who is called a ____, pays a monthly subscription fee
c. the subscriber is entitled to obtain hospital/medical services from any hospital or doctor provide that is a ___ of the service org network
d. if the subscriber were to go to an out of network provider, will they be covered?

Answer 21

hospital, physician’s
subscriber
member
no

Question 22

A PPO is an organization that organizes groups of hospitals and physicians to provide medical services at _____ ____ ___

Answer 22

negotiated discounted

Question 23

Insurance companies encourage their insureds to stay in the network but allowing their insureds lower ____ and ____ requirements to apply if they stay in network

Answer 23

deductibles and coinsurance

Question 24

if they go out of network, higher ____ and ____ requirements will apply

Answer 24

deductibles and coinsurance

Question 25

HMOs provide a list of ____ ___ ____ that are usually similar to major medical benefits

Answer 25

specified health services

Question 26

the covered individual is entitled to obtain medical services from ____ or ____ service providers that are part of the plan networks

Answer 26

hospital, physician

Question 27

HMO's put the ____ limitations on where the insured can go for service

Answer 27

most

Question 28

HMOs provide the most liberal benefits for non risk type expenses such as ____, ___ ____ and other forms of preventative medicine

Answer 28

physicals, wellness programs

Question 29

HMOs provide the ____ premium rates of the various types of health insurance organizations

Answer 29

lowest

Question 30

HMOs practice ____ ____ to the greatest extent of any insurance organization

Answer 30

managed healthcare

Question 31

insurance organizations have many ways of managing health care of their insureds. their objective is provide proper, effective ____ ___, while at the same time, containing ___ and avoiding unnecessary ____

Answer 31

health care, costs, services

Question 32

although managed healthcare is practiced to some extent by all types of insurance organizations, it is mostly associated with ___ ____ ___

Answer 32

HMOs

Question 33

HMOs usually provide guidelines to their network hospital and physician service providers as to what care and how much care is ____, ___ and ____ for each particular condition

Answer 33

reasonable effective efficient

Question 34

the primary care physician is aka as what

Answer 34

the gatekeeper

Question 35

HMOs sometimes compensate their network hospital and physician service providers on a ____ __ basis.

Answer 35

capitated fee

Question 36

capitated fees provide the service provider with a ___ ____ to avoid unnecessary treatment and to contain ___

Answer 36

financial incentive, cost

Question 37

Point of service plans are issued by?

Answer 37

HMOs

Question 38

due to the high level of managed health care practiced by the HMO for in network treatment, the insured receives a ___ premium rate compared to private insurance risk indemnity plans

Answer 38

lower

Question 39

the insured also has the benefit of being able to go to hospital/medical service providers that are outside of the HMO network with ___ deductible and coinsurance requirements applying

Answer 39

higher

Question 40

private insurance company risk indemnity plans, BCBS provides service plans, PPO and HMO plans usually ____ benefits by benefit amounts to which the insured is entitled to coverage under the federal and state gov insurance programs

Answer 40

reduce

Question 41

when one plan reduces benefits by benefit amounts to which the insured is entitled up coverage under another plan, it is called ____ ____

Answer 41

coordinating benefits

Question 42

Workers comp insurance is a type of _____ insurance, not health insurance

Answer 42

casualty

Question 43

private insurance company risk indemnity plans, BCBS service plans, PPO plans and HMO plans usually ____ expenses covered by workers comp insurance

Answer 43

exclude

Question 44

when one plan excludes coverage for expenses covered under another plan, it is referred to as ______ ___

Answer 44

coordinating benefits

Question 45

when after an insurance organization pays a claim, it becomes entitled to the insured's rights to make a claim against another insurance org to recover the benefits they have paid

Answer 45

subrogation

Question 46

insuring too many health conditions insureds have before the policy is issued, causing premium rates to be inadequate to pay claims. two policy policy provisions that insurance companies use in health insurance to avoid ____ ____ are pre-existing conditions clauses and impairment riders

Answer 46

adverse selection

Question 47

pre-existing condition clauses and impairment riders may not be used only in policies that do not come under the ___ ___ ____

Answer 47

affordable care act

Question 48

it is an optional provision included in some health insurance policies to avoid adverse selection

Answer 48

pre existing condition clause

Question 49

the furthest an insurance company can go in classifying a condition as pre existing under the pre existing condition clause is

Answer 49

two years

Question 50

the farthest back the pre existing condition clause is

Answer 50

two years

Question 51

what does manifested mean?

Answer 51

made clear

Question 52

an optional provision included in some policies to manage adverse selection a. it excludes a particular health condition, or group of health conditions specifically

Answer 52

impairment rider - only in individual policies

Question 53

the purpose of ____ expense insurance is to protect insureds against the financial risk of illness or injury expenses that cannot individually afford

Answer 53

hospital/medical

Question 54

hospital expense coverage | pays benefits for only hospital expenses such as ___, ___ or ____ may apply

Answer 54

deductibles, coinsurance, and or copayments

Question 55

benefits that pay for hospital room, board, general nursing care and other routine services. per day and maximum (____) limits apply

Answer 55

daily hospital benefits, aggregate

Question 56

benefits that pay for hospital laboratory, x ray, anesthetic, operating room and medicine and dressing expenses. limits are expressed as a multiple of the daily hospital benefits

Answer 56

miscellaneous hospital expense benefits

Question 57

pays for hospital surgical procedures specified in the policy as well as any other of the insured may be required to have. Benefits can be expressed either according to a surgical schedule or a surgical relative value table. Insurance company will pay 100% of major procedure and 50% of the minor procedure

Answer 57

surgical expense benefits

Question 58

pays doctor charges incurred in the hospital and sometimes after being discharged for conditions treated in the hospital

Answer 58

physicians expense benefits

Question 59

this can be used as a separate policy by itself or along with Hospital Expense coverage

Answer 59

major medical coverage

Question 60

major medical coverage ___, ___, and ____ ____ hospital and medical expenses to include: A. hospital expenses not covered by hospital expense coverage B. hospital out-patient expenses C. doctor office expenses D. major medical coverage sometimes covers prescription drugs. Other times its a separate coverage

Answer 60

usual, reasonable, and customary eligible

Question 61

A. insurance organizations survey health care providers to determine what the normal range of fees charged for specified services is for each region in which the insurance organization issues policies. B. most policies cover only expenses that do not exceed what the insurance organization has determined to be reasonable and customary.

Answer 61

usual, reasonable, and customary charges

Question 62

are charges for services that are covered under the insurance policy

Answer 62

eligible expenses

Question 63

A. the insurance company pays a percentage of usual, reasonable, and customary eligible expenses. The insured pays the rest until the deductible B. the stated level of eligible expenses where the insurance company begins indemnifying 100% of the insured's expenses, and where the insured's losses stop, is called a stop loss

Answer 63

policyholder participation/ coinsurance

Question 64

is the maximum the insured will be required to pay under both the deductible and coinsurance requirements

Answer 64

maximum out-of-pocket

Question 65

a small specific deductible amount that the insured must pay before the insurance company begins to indemnify for a particular type of expense

Answer 65

co-payment

Question 66

the purpose of the ___, ___, and ___ ___ requirements is to encourage the insured to avoid unnecessary expenses and to eliminate small claims that the insured can afford and which would cost the insurance company to administer

Answer 66

co-payment, deductible, and policyholder participation/ coinsurance

Question 67

major medical always has a high limit of liability. no annual of lifetime limits of liability apply to the ACA. qualified health plan

Answer 67

high limit of liability

Question 68

are covered only if required as a result of an accident

Answer 68

cosmetic and dental surgery

Question 69

taxation of premium and benefits of health insurance A. premiums on ___ hospital/ medical expense coverage ___ can be tax deducted by the insured B. premiums paid by an employer on ___ hospital/medical expense coverage usually can be tax deducted by the employer (___) C. there is usually ___ tax on individual or group hospital/ medical expense benefits

Answer 69

individual, sometimes group tax qualified no

Question 70

programs through which hospital/ medical expense plans are issued: 1. HSA 2. MSA 3. HRA 4. FSA

Answer 70

1. Health savings accounts 2. medical savings accounts 3. health reimbursement accounts 4. flexible spending accounts

Question 71

a. are accounts that can be established by an individual, family, or any size employer to cover hospital/medical expenses not covered by a high deductible health plan b. high deductibles apply on the health insurance coverage c. part of all of the deductible can be contributed annually to a health savings accounts d. contributions to health savings accounts are usually tax deductible e. HSA balances carry over to the next year

Answer 71

health savings accounts (HSA)

Question 72

are very similar to HSA. they are available only employers of certain sizes

Answer 72

medical savings accounts MSAs

Question 73

Twelve ____ uniform policy provisions that are required in all ___ accident and health insurance plans

Answer 73

required, individual

Question 74

First required uniform policy provision - only includes whats in the contract - no change is official until it is signed by an officer of the insurance comp

Answer 74

entire policy - changes

Question 75

2nd required provisions - pre existing condition clauses - incontestability - proving fraud

Answer 75

time limit on certain defenses - incontestability - 2yrs

Question 76

3rd provision | 7, 10 and 31 days

Answer 76

grace period

Question 77

4th provision | 45 days, 10 day waiting period - illness claims

Answer 77

reinstatement

Question 78

5th prov. | - notice of loss - 20 days

Answer 78

notice of claim

Question 79

6th prov | -15 days from notice of loss

Answer 79

claim forms

Question 80

7th prov | - 90 days from notice of loss and every 6 months

Answer 80

proof of loss

Question 81

8th prov | time of ___ of claims - immediately and no less often than monthly

Answer 81

time of payment of claims

Question 82

9th prov | ____ of claims

Answer 82

payment

Question 83

10th prov | Physical examination and ____

Answer 83

autopsy

Question 84

11th prov. | - ____ actions - 60 days, 3 years

Answer 84

legal actions

Question 85

12th prov | change of ____

Answer 85

beneficiary

Question 86

the clause that states the insurance company's promise to indemnify

Answer 86

the insuring clause

Question 87

children must be allowed to be covered as dependents under their parent's policy through age 25 until their age 26 bdays

Answer 87

dependent coverage

Question 88

______ clause a. a transfer of one of more rights in a policy to another b. the policyowner has the right to assign benefits of a policy or ownership of a policy to another c. ins co will not be responsible for the validity of the assignement

Answer 88

assignment

Question 89

Renewability provisions 1. _______ renewable a. the policy is renewable at the ins co's option b. the insured has no guarantee that the policy will be renewed 2. ______ renewable a. ins co can refuse to renew only for reasons stated in the policy 3. ____ renewable a. ins co must renew b. ins co can change rates only by class c. all hosp/med policies covering people covering people under age 65 which come under the ACA must be guaranteed renewable 4. ____ and _____ renewable a. ins co must renew b. ins co cannot cancel the policy c. premium rates cannot be changed at all d. this is found only in stated value policies

Answer 89

optionally conditionally guaranteed noncancelable and guaranteed

Question 90

if included it excludes disabilities caused by injuries sustained while on active duty in the armed services

Answer 90

injuries while in armed forces

Question 91

most apps ask if the insured flies or intends to fly as other than a fare paying passenger on a commercial airline within two years. if the insured does, they can choose either a rating or an aviation exclusion. if the aviation exclusion is chosen, then the insured will not be covered while flying other than fare paying passenger on commercial airline

Answer 91

injuries in aircraft

Question 92

policies that come under the ACA must cover maternity expenses

Answer 92

pregnancy

Question 93

mental infirmity

Answer 93

psychological or psychiatric couseling

Question 94

a. an insured is a ____ ____ if they are at least 18, not on drugs or drunk, and has not been adjudicated mentally incompetent before buying the policy b. if not, the policy is voidable by the insured

Answer 94

competent parties

Question 95

it promises to pay (indemnify) subject to conditions (requirements) being met at the time that the policy is purchased and at time of the claim

Answer 95

conditional contract

Question 96

once the conditions are met, only one party is required to perform (ins co)

Answer 96

unilateral contract

Question 97

one party, the ins co, writes the contract and determines the terms. the other party, the insured, accepts or rejects the contract and terms that the ins co has written

Answer 97

contract of adhesion