Medical Expense Insurance Practice Exam

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• What is a copayment?
• What is open enrollment?
• Do health plans commonly have networks, and do coverage terms vary by policy?
• In a major medical policy, what provision requires the insured to pay part of a loss after the insurer pays a portion?
• What is a copayment in medical expense insurance?
• What does reinstatement in a health policy generally allow?
• Do most medical expense policies cover prescription drugs automatically?
• What does a maternity or dental rider do for a base health policy?
• In a standard medical expense policy, custodial care is typically:
• Which phrase refers to the fees charged by a healthcare professional?
• What features differentiate individual health insurance from group plans?
• How do primary and secondary payers determine which plan pays first?
• Which of these options can an individual use their medical flexible spending account to pay for?
• What is the purpose of an "other insurance" clause in a health insurance policy?
• What best describes the intent of a coinsurance clause in a Major Medical policy?
• What is the total out-of-pocket expense for M on a $2,200 claim under the described policy?
• Open enrollment is not used for which of the following actions?
• If age was misstated on a policy and corrected later, what might the insurer do?
• Do health insurance plans typically cover mental health and substance use treatment?
• In reinstatement, what is typically required to restore a lapsed policy?
• Which statement describes subrogation in health insurance?
• Which policy type offers higher limits and is intended to cover catastrophic costs?
• Which cost-sharing component begins after the deductible is satisfied?
• Which health insurance plan is primarily designed to cover hospital room and board expenses?
• What is the role of precertification in health insurance?
• What is the purpose of a medical expense rider?
• During in-network service, how are expenses typically determined?
• A policy that provides coverage on an in-hospital basis only and has a limited daily room and board benefit is best described as which type?
• Major Medical policies typically contain which of the following features?
• Why is a high-deductible plan often paired with a Health Savings Account (HSA)?
• What is an embedded deductible?
• What information does an EOB typically include?
• What is a waiting period for preexisting conditions?
• How does a family deductible differ from individual deductibles?
• With a $200 deductible and 80% coinsurance, after meeting the deductible, what percentage of the remaining allowed charges is paid by the insurer?
• Which of the following best defines the deductible concept?
• How does assignment of benefits interact with provider billing?
• A basic hospital policy typically covers which of the following?
• What is a free-look period?
• Which medical expense is NOT typically covered by cancer insurance?
• What is the typical effect of renewability provisions on premium changes?
• 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
• Basic Medical Expense Insurance has lower benefit limits than Major Medical. Which statement best describes this relationship?
• Which of the following BEST describes a hospital indemnity policy?
• Which statement is true about the relationship between deductible and copayments?
• What is a typical time limit for submitting a claim?
• How does a hospital indemnity plan differ from a pure medical expense plan?
• Under guaranteed issue, which statement is true?
• What is reinstatement in the context of a health insurance policy?
• This deductible provision applies when more than one family member is involved in a common accident or illness; only one deductible amount shall be applied.
• What determines the claim M is eligible for under a basic Hospital/Surgical Expense policy?
• Which service is NOT included under hospitalization expense coverage?
• In a comprehensive major medical policy, which service is typically not covered under Eligible Expenses, i.e., considered an exception?
• What is a stop-loss provision in a medical expense policy?
• What is the difference between in-network and out-of-network coverage?
• In order to establish a Health Reimbursement Arrangement (HRA), it MUST
• In most health plans, deductibles apply to which type of services?
• How many deductibles per calendar year are allowed under the described policy?
• How is preventive care typically treated in many health plans?
• What does it mean for a service to be medically necessary?
• Are routine physical examinations usually covered under basic medical expense policies?
• Which statement is true about the relationship between deductible and coinsurance in the example?
• What is an out-of-pocket maximum?
• What is a waiting or probationary period in medical expense insurance?
• What is the purpose of a preauthorization process?
• Which statement correctly describes the relationship between deductible and coinsurance?
• What best describes the out-of-pocket maximum?
• What is the difference between in-network and out-of-network benefits?
• If M has a Major Medical policy with a $200 flat deductible and an 80% coinsurance clause, and a $2,200 eligible expense is incurred, how much will the insurer pay for this claim?
• What is a common exclusion in many medical expense policies?
• Why is it important to review network status when selecting medical expense coverage?
• How do pre-existing conditions typically affect coverage?
• What is the typical effect of a deductible in a health insurance policy?
• Which statement about Health Reimbursement Arrangements (HRA) is correct?
• In medical expense insurance, maternity benefits are most commonly found in which form?
• The individual Health Insurance policy that offers the broadest protection is a(n) ___ policy
• With a limit of four deductibles per calendar year, if two deductibles have already been paid in a given year, how many more deductibles can be paid in that same year?
• Which of the following is an example of a medical expense rider?
• In a group medical plan, what does the employee contribution refer to?
• How does a family deductible impact when benefits begin for dependents?
• Within a comprehensive major medical policy, the Eligible Expenses provision is best described as identifying what?
• An insured covered by a group Major Medical plan is hospitalized after injuries that resulted from an automobile accident. Assuming the plan had 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?
• In an 80/20 coinsurance arrangement, after the deductible is satisfied, the insured pays 20% of covered expenses.
• How do ACA requirements affect preventive services?
• How do copayments relate to deductibles?
• What does assigned benefits mean in a medical expense claim?
• What is an explanation of benefits (EOB) form and its purpose?
• Upon reinstatement after a lapse, what may occur regarding pre-existing conditions?
• A health reimbursement arrangement MUST be established
• Are cosmetic procedures generally covered by medical expense insurance?
• Which provision allows a portion of any used medical benefits to be restored after a certain amount of benefit has been used, or after the policy has been in effect for a period?
• What is a claims appeal process?
• Which statement correctly describes the function of a flat deductible in a major medical policy?
• In the Major Medical example, how much is the deductible amount?
• In a family accident when multiple family members are affected, how many deductibles apply?
• What does 'usual, customary and reasonable' (UCR) mean in claims payments?
• What is a per-incident limit versus a per-year limit?
• Which of the following situations does a critical illness plan cover?
• Which statement best describes the difference between a group medical expense policy and an individual medical expense policy?
• What is a fixed per-day hospital benefit?
• Which statement best describes prescription drug coverage in major medical plans?
• If a plan has a $2,000 deductible and 30% coinsurance, and a covered bill of $5,000, what is the insured's payment after meeting the deductible?
• What is subrogation in health insurance?
• Which of the following is a characteristic of a preferred provider organization (PPO)?
• What is stop-loss coverage in a group health plan?
• What is the primary purpose of a deductible in health insurance?
• Which statement best describes maternity coverage in health insurance plans?
• In a multi-plan scenario, which statement about which plan pays first is correct?
• How is a deductible defined in a medical expense policy?
• Which statement about the relationship between deductibles, coinsurance and premiums is most accurate?
• If a prospective insured conceals a pre-existing heart condition and a policy is issued, upon discovery the company will
• Under a Hospital/Surgical Expense policy with a deductible of $500 and four deductibles per calendar year, if two claims in 2013 each exceed the deductible, what is the 2013 out-of-pocket?
• Which statement best describes a plan with no deductible?
• What is the purpose of an appeals process in denied claims?
• What is the purpose of a preexisting condition look-back period?
• Which document is typically used to verify expenses and dates of service when filing a claim?
• What is a typical reason rehabilitation services coverage varies?
• What is the difference between indemnity payment and service-based payment?
• What is the standard requirement for timely filing of medical expense claims?
• What are exclusions for experimental or investigational treatments?
• What is the primary purpose of a deductible in a medical expense insurance policy?
• If a policyholder's age is misstated, what action might the insurer take?
• Is custodial care typically covered by medical expense insurance?
• Which statement best describes the usual treatment of a pre-existing condition when a policy is issued?
• What is the appeals process for denied claims?
• Which statement best describes the purpose of coordinating with other coverage across plans?
• What does guaranteed issue mean in health insurance?
• For which of the following expenses does a basic hospital policy pay?
• What happens after the out-of-pocket maximum is reached?
• In the context of medical expense insurance, what is precertification (preauthorization) and its purpose?
• What is the 'free look' period?
• Distinguish between annual maximum and lifetime maximum limits.
• Why are eligibility rules important in medical expense insurance?
• If J's Major Medical policy has a $2,000 deductible and an 80/20 coinsurance clause, what would J pay for a $10,000 hospitalization bill?
• Are ambulance services commonly covered by medical expense policies?
• What is "proof of loss"?
• Which statement accurately describes guaranteed renewable provisions?
• The first portion of a covered Major Medical expense that the insured is required to pay is called the
• A catastrophic illness would be best covered by which health insurance plan?
• What is the typical claims submission documentation required for medical expense claims?
• Do medical expense policies typically cover durable medical equipment (DME)?
• If a policy has an annual maximum, what happens to benefits after the cap is reached within a calendar year?
• What is the difference between non-cancelable and guaranteed renewable policies?
• Which statement BEST defines usual, customary, and reasonable (UCR) charges?
• What is a grace period in health insurance?
• What is required when filing a medical expense claim?
• What is the primary purpose of medical expense insurance?
• In a policy with a deductible and coinsurance, the first payment by the insured is typically the:
• In a basic hospital policy compared to major medical, which is true?
• This policy will only pay for a semi-private room. This phrase is considered to be a(n):
• When does a deductible reset?
• How does maternity coverage typically appear in medical expense policies?
• What happens if a policyholder cannot pay premiums?
• How does a major medical policy differ from a basic hospital policy?
• How can misstatement of age affect an existing medical expense policy?
• How are out-of-network emergency services typically treated?
• Is hospice care generally included in medical expense insurance?
• Generally, how long is a benefit period for a Major Medical Expense Plan?
• How is a pre-existing condition typically handled in medical expense insurance?
• Which of the following describes a high-deductible health plan?
• Which of the following is NOT a limited benefit plan?
• Which factor most influences the deductible amount in a medical expense policy?
• In a major medical policy, what is the role of the deductible?
• In routine physical examinations, how is coverage typically treated in basic medical expense policies?
• Name three common exclusions found in medical expense policies.
• 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?
• What happens on reinstatement after a lapse?
• Which statement about major medical benefits is false?
• Which statement best differentiates noncancelable from guaranteed renewable provisions?
• What role do rehabilitation services play in medical expense insurance?
• What statement about deductibles is true?
• Basic Hospital and Surgical policy benefits are:
• Do prescription drugs generally get covered under standard medical expense policies?
• What does the deductible refer to in a health insurance policy?
• In medical expense insurance, when is a claim considered incurred?
• Which type of health coverage frequently uses a deductible?
• What is a common rule regarding cosmetic or elective surgery?
• In the context of limits, which option describes a per-incident limit?
• Which type of policy provides coverage only for specific illnesses such as cancer or stroke?
• What is typically true about out-of-network costs compared to in-network?
• What is the purpose of benefit schedules in medical expense insurance?
• C with major medical policy 80/20 coinsurance and a $400 deductible. What is the MAXIMUM C will pay if the covered medical expenses are $2000?
• After the deductible is satisfied, who typically pays the coinsurance in a major medical policy?
• Differentiate between a basic medical expense policy and a major medical policy.
• Which statement correctly defines an emergency under medical expense insurance?
• To qualify for a tax-exempt Health Savings Account (HSA), you must be enrolled in which type of plan?
• During the waiting period in a medical expense policy, which of the following is most likely to be payable?
• How does coinsurance differ from a copayment in medical expense insurance?
• What is coordination of benefits (COB) and why is it used?
• What is the overall purpose of a policy's renewability provisions?
• An individual has a major medical policy with a $5,000 deductible and an 80/20 coinsurance clause. If total covered medical expenses are $15,000, how much must the insured pay?
• What is an out-of-pocket maximum and what happens when it is reached?
• How does coinsurance operate after the deductible is met?
• Which statement best describes dental care indemnity coverage?
• Which statement best describes coverage for cosmetic procedures when a policy includes a rider?
• Which statement describes formulary restrictions in prescription drug coverage?
• Do medical expense policies typically provide mental health coverage?
• Which statement best describes underwriting in group versus individual plans?
• How does subrogation relate to COB?
• What is the typical effect of a patient taking out-of-network emergency services with regard to reimbursement?
• Which services are typically covered by medical expense insurance?
• What is a grace period in medical expense insurance?
• Which statement about the free-look period is true?
• Which is a consequence of a deductible on the insured's costs?
• What is subrogation in the context of medical expense insurance?
• All of these are characteristics of a Health Reimbursement Arrangement (HRA) Except:
• What is the term for the policy arrangement that combines Major Medical coverage with Basic Hospital/Surgical coverage?
• Under a Basic Medical Expense policy, what does the hospitalization expense portion cover?
• This type of deductible provision waives the deductible for all family members after some have satisfied individual deductibles within the same year.
• How does coordination of benefits work between two employer-sponsored plans?
• The contestability period in health insurance is described as which?
• Which statement best describes a hospital indemnity policy's benefit structure?
• What is an insurance rider?
• What is the typical process to challenge a denied claim?
• In a policy with 80/20 coinsurance after the deductible, the insured pays:
• How would you calculate a claim payment under coinsurance?
• What does coordination of benefits accomplish?
• Which statement about Major Medical Expense plans is true?
• Which statement is true about guaranteed renewable policies?
• Why might precertification impact coverage?
• In Major Medical Expense policies, what is the objective of a Stop Loss provision?
• In a noncancelable policy, which is guaranteed by the insurer?
• Which service is commonly excluded from medical expense policies?
• In a Major Medical policy with an 80/20 coinsurance, after the deductible is satisfied, what percentage of eligible expenses is typically paid by the insurer?
• How does a calendar-year deductible differ from a lifetime deductible?
• Comprehensive Major Medical policies usually combine
• Which policy feature allows an insured to defer current health charges to the following year's deductible instead of the current year's deductible?
• Which statement best describes the effect of assigned benefits on payment flow?
• Using the same J's policy (2,000 deductible, 80/20 coinsurance), if the total medical bill were $6,000, how much would J pay?
• How does a calendar-year deductible affect claims?
• Which statement about maternity coverage is accurate?
• Q is hospitalized for 3 days and receives a bill for $10,100. Q has a Major Medical policy with a $100 deductible and 80/20 coinsurance. How much will Q be responsible for paying on this claim?
• What is the purpose of a policy grace period?
• Which of the following costs would a basic hospital/surgical policy likely cover?
• What is the status of coverage for experimental or investigative procedures?
• Ambulance services coverage typically falls under which category of services in most policies?
• What is the significance of a lifetime maximum in health plans?
• Which feature is most closely associated with group health plans and is often highlighted in contrast to individual plans?
• In a policy with multiple insurers, what is the purpose of coordination of benefits (COB)?