Medical Plans

A child of the insured is incapable of self-support because of a physical handicap. The child has reached the limiting age for dependents. When can coverage continue under the health insurance policy?

If premium is paid, and proof of the dependent's handicap is provided within a specified period of time

A health insurance plan which involves financing, managing, and delivery of health care services and involves a group of providers who share in the financial risk of the plan or who have an incentive to deliver cost effective service, is called

Managed Care Plan

A man bought an individual health insurance policy for himself. Which of the following roles does he now legally have?

Both subscriber and insured

A man's physician submits claim information to his insurer before she actually performs a medical procedure on him. She is doing this to see if the procedure is covered under the patient's insurance plan and for how much. This is an example of

Prospective review

A married couple is covered under a group health insurance plan at the husband's place of employment. When the wife gave birth to their first child, what must the husband do in order to have coverage for the child?

Notify the insurer within 31 days in order for coverage to continue without any evidence of insurability

A new employee who meets HIPAA eligibility requirements must be issued health coverage on what basis?


An applicant has a history of heart disease in his family, so he would like to buy a health insurance policy that strictly covers heart disease. What type of policy is this?

Dread disease coverage

An insured is admitted to the hospital for surgery on a herniated disk. The insurance company monitors the treatment and progress in order to make sure that everything proceeds according to the insurer's schedule. This is called

Concurrent review

An insured has a major medical policy with a $500 deductible and a coinsurance clause of 80/20. If he incurs medical expenses of $4,000, the insurer would pay

$2,800 (4,000 - 500 = 3500 - 700 (20% of 3500 = 2800)).

An insured has a major medical policy with a $500 deductible and 80/20 coinsurance. The insured is hospitalized and sustains a $2,500 bill. What is the maximum amount that the insured will have to pay?

$900 (500 deductible + 400 (20% of 2,000) = 900).

How are the HMO territories typically divided?

Geographic areas

In health insurance, if a doctor charges $50 more than what the insurance company considers usual, customary and reasonable, the extra cost

It is not covered

In a POS plan, benefits for covered services when self-referring (without having your primary care physician arrange for the service) are generally

More expensive

Maximum benefits for a major medical plan are usually lifetime


Most health insurance policies exclude all of the following EXCEPT

Accidental injury

To be eligible under HIPAA regulations, for how long should an individual converting to an individual health plan have been covered under the previous group plan?

18 months

The HMO Act of 1973 required employers to offer an HMO plan as an alternative to regular health plans if the company had more than 25 employees. How has this plan since changed?

Employers are no longer forced to offer HMO plans

What is the goal of the HMO?

Early detection through regular checkups

What process will the insurance company use to monitor the insured's hospital stay to make sure that everything is proceeding according to schedule?

Concurrent review

Which of the following is another name for a primary care physician in an HMO?


Which of the following terms describes a specific dollar amount of the cost of care that must be paid by the member?


Which of the following is true regarding inpatient hospital care for HMO members?

Care can be provided outside of the service area

Which of the following is NOT a characteristic or a service of an HMO plan?

Contracting with insurance companies

Which of the following is true of a PPO?

Its goal is to channel patients to providers that discount services

Which of the following is the term for the specific dollar amount that must be paid by an HMO member for a service?