Health Insurance Policies Flashcards
6 cards from real Life and Health California Exam practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Health Insurance Policies flashcards as text
What is a 'deductible carryover' provision in a major medical policy?
Answer: It allows expenses incurred in the last 3 months of the year to apply to the next year's deductible
The carryover provision allows medical expenses incurred in the final quarter of the year to be applied toward satisfying the following year's deductible.
Under an exclusive provider organization (EPO), what happens if the insured uses an out-of-network provider for non-emergency care?
Answer: No benefits are paid
EPOs do not cover non-emergency care received outside the network—if the insured uses an out-of-network provider, they receive no benefits.
A 'family deductible' in a health insurance policy means:
Answer: Once total family expenses meet the family deductible, further covered expenses are paid at 100%
Once the combined out-of-pocket expenses of covered family members reach the family deductible cap, the insurer pays 100% for all remaining covered family expenses.
Under the California Insurance Code, individual health insurance policies must provide coverage for which of the following mental health services?
Answer: Mental health and substance use disorder services at parity with medical/surgical benefits
California's mental health parity laws require insurers to cover mental health and substance use disorder services at the same level as medical and surgical benefits.
Which type of health policy provision gives the insured the right to renew the policy each year, but the insurer may change the premium at renewal?
Answer: Guaranteed renewable
A guaranteed renewable policy cannot be canceled by the insurer but allows the insurer to adjust premiums at renewal for an entire class of policies.
What is the purpose of a 'coordination of benefits' (COB) provision in group health insurance?
Answer: To prevent the insured from collecting more than 100% of covered expenses when covered by more than one plan
The COB provision prevents over-insurance by limiting total benefit payments from all carriers to no more than 100% of actual covered expenses.