Chapter 13: Health Insurance Providers

An HMO that involves a partnership of physicians and other providers who practice out of a central facility is called a(n) group HMO federal HMO central HMO managed HMO

A)

Individual health insurance coverage typically excludes injuries at an employee's workplace because it's covered by the state Workers' Compensation program it's covered by Medicare it's covered by Medicaid it's self-funded by the employer

A)

Jon's health plan pays benefits of 90% for in-network providers and 70% for out-of-network providers. What kind of plan is this? HMO PPO MET MEWA

B)

Who acts as the gatekeeper in a Health Maintenance Organization (HMO)? Policyowner HMO Arbritrator Primary care physician Insurance company

C)

Individuals become eligible for Medicare Part A benefits at what age? 50 59 1/2 62 65

D)

A medical provider that accepts Medicare Assignment must accept payment based upon a defined Medicare schedule and bill the insured for any difference accept payment based upon a defined Medicare schedule and negotiate any excess fees accept payment based upon a defined Medicare schedule and bill no more than 15% of the excess charges accept payment based upon a defined Medicare schedule as payment in full

D)

An individual can enroll in a Part C Medicare Advantage Plan at what time? When becoming eligible for Medicaid At age of retirement Age 59 1/2 When becoming eligible for Medicare

D)

At what age will a person normally enroll with an insurance carrier under a Part C Medicare Advantage Plan? Age 59 1/2 Age 60 Age 62 Age 65

D)

Disabled workers are covered under Workers' Compensation medical expense benefits for how long? 6 months 3 years 10 years No limit

D)

Funding for Medicare Part B is partially provided by Municipal bonds State bonds private insurers user premiums

D)

How is Medicare Part B funded? Employer taxes Payroll taxes User premiums General tax revenue and user premiums

D)

Medicaid is a government-funded program designed to provide health care to all individuals over the age of 65 all individuals who carry Medicare supplemental insurance anyone who does not have a proper caregiver poor people

D)

Medicaid is intended for people with kidney failure people aged 65 and older unemployed people poverty stricken people

D)

Small employers who are sponsored by an insurer to provide group benefits to its employees are called Fraternal Benefit Society Surplus lines brokers Lloyd of London MEWA

D)

When a preferred provider organization (PPO) insured goes out-of-network, which of the following actions occur? The insured will pay a reduced amount The benefits are taxable The insured has lower out-of-pocket expenses The insurer will pay a reduced amount

D)

Which of these is NOT a qualifying event for Medicare? On Social Security disability for over 2 years Kidney failure Age 65 or older Falling below the federal poverty level

D)

Which of these will typically authorize treatment from a specialist? Administrator Policyowner Insurance company Gatekeeper

D)

Which payment method for a health claim settlement is typically made directly to the provider of the services? Settlement Fee-for-service Premium payment Prepaid

D)

Which statement about Health Maintenance Organizations is NOT true? Members minimize out-of-pocket expenses by using HMO network providers Subscribers pay a fixed periodic fee to the HMO HMOs are known for stressing preventive care When a member uses out-of-network providers, a higher monthly fee is charged

D)

Which statement regarding Medicare is true? Nursing home coverage is covered by Part B Benefits for prescription drugs are covered exclusively by Part A Medicare is available only to individuals age 60 and older Benefits for diagnostic tests and X-rays performed on an outpatient basis are provided by Part B

D)

Which of the following services are health maintenance organizations (HMO's) NOT required to provide? Emergency services Hospitalization Preventative services Prescription drugs

D) Prescription drugs

Medicare provides coverage for each of the following EXCEPT hospital room and board doctor and surgeon services prescription drugs custodial care

D) custodial care

Paul is an employee who caught a disease unique to the trade in which he was exposed to. Paul has a(n) genetic predisposition worksite malady contagious disease occupational disease

D) occupational disease

Medicare Part A covers what type of care? Skilled nursing facility care Major Medical facility care Custodial facility care Respite facility care

A) Skilled nursing facility care

Medicare Part A does not pay for medical benefits provided for treatment in a skilled nursing facility beyond 30 days 60 days 100 days 120 days

C)

Medicare Part B covers long-term care hospital room and board doctor's charges prescription drugs

C)

Donna and Mary were racing bicycles in a store parking lot while being cheered on by fellow employees. Mary ran into John, another employee, who happened to be taking out the garbage. Both Mary and John are injured. Who would most likely be covered under Workers' Compensation? John Mary John and Mary Neither of them

A)

The Federal Employees Benefit Program consists of two types of health plans for federal civilian employees. The two plans are fee-for-service and prepaid ambulatory facility blanket

A)

The open enrollment period for Medicare Part B is January 1 through March 31 January 1 through April 30 January 1 through May 31 January 1 through June 30

A)

Which of the following does Medicare Part A NOT provide coverage for? Doctor's services Hospice Hospitalization Inpatient care

A)

Which of the following healthcare providers provides both the healthcare services and healthcare coverage? Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Multiple Employer Welfare Arrangements (MEWA) Tri-Care

A)

Maria is a Preferred Provider Organization (PPO) subscriber and received care from an out-of-network provider. Which of the following is the likely result? Care is covered Care is not covered Care is only covered in a government facility Care is only covered if primary care physician gives a referral

A) Care is covered

Medicare Part B covers long-term care hospitalization physician expenses disability

C)

A 70-year old insured individual has suffered from kidney failure for the past 24 months. She is covered by her spouse's large-group employer plan. How will Medicare be utilized in this situation? Will be the primary insurer and pay for 100% of covered expenses Will be the secondary insurer and pay for claims not fully covered by the group plan Will not pay for any of the covered expenses Will be the primary insurer and the group plan will be secondary

B)

After the annual deductible is met, a Medicare Part B patient will pay ___ of the remaining covered expenses. 0% 20% 50% 100%

B)

An individual covered under a Blue Cross Blue Shield plan is called a(n) participant subscriber policyowner insured

B)

At age 65, which of the following is available at no cost to all individuals? Medicare Select Medicare Part A Medicare Part B Medicare Supplemental insurance

B)

How is a Medicare claim submitted? Expenses are submitted to Medicare by the Commissioner Expenses are submitted to Medicare by the health provider Expenses are submitted to Medicare by the patient Expenses are submitted to Medicare by an arbitrator

B)

Medicare Part B has an initial enrollment period. How many months after an individual's 65th birthday month does this enrollment period end? 1 months 3 months 6 months 8 months

B)

Part A Hospital expense coverage provided under Medicare is automatically made available to each of the following EXCEPT A 50-year old individual who has qualified for SSDI in the last 24 months A 70-year old NOT eligible for Social Security A 55-year old suffering from kidney failure A 65-year old retiree

B)

What is Medicare Part B also known as? Medicare supplement Supplementary medical insurance Comprehensive insurance Medicaid

B)

What type of injury would NOT be covered under a health insurance policy? Accidental Work-related Sports-related Recreational

B)

When comparing an HMO to a PPO, the PPO always requires service in a network provides a greater choice of providers always requires a referral to specialists is a prepaid medical service plan

B)

Which of the following is Medicare Part B also known as? Hospital insurance Medical insurance Long-term care insurance Medigap

B)

Which of the following is NOT a characteristic of a preferred provider organization (PPO)? Usually operate on a fee-for-service basis Primary physicians serve as gatekeepers Patient fees are discounted Provides a wide choice of physicians

B)

Which of the following is NOT taken into consideration when determining eligibility for Medicare benefits? Chronic kidney disease Income Age Social Security disability

B) Income

Individuals age 65 or older are exclusively eligible for which optional program? Medicare Part A Medicare Part B MET's Long-term care

B) Medicare Part B

Which of the following is an example of a third-party administrator? Outside organization that manages a sales team Outside organization that processes claims for an employer's self-funded group plan Outside organization that serves as an arbitrator in Social Security claims Outside organization that conducts investigations into fraudulent claims

B) Outside organization that processes claims for

A closed network plan offers a a primary physician copay of $25. If a subscriber chooses a primary care physician outside of the network, the subscriber will likely pay $0 $25 100% of the billed amount 100% of the allowed amount

C)

A health care provider claim may be settled using which of the following payment methods? Litigation Unfair claim settlement Fee-for-service Prepaid expense

C)

After the annual deductible is met, Medicare Part B will pay ___ of the remaining approved charges. 20% 40% 80% 100%

C)

An employee for XYZ Corp is injured on the job. Where does coverage for the employee's injuries come from? Employer's group health plan Employer's self-insured fund Workers' Compensation Employee's individual health policy

C)

Coverage for care received from a network provider pays more than care received from a non-network provider in what type of health plan? Hospital indemnity Self-insured plan Preferred Provider Organization (PPO) Health Maintenance Organization (HMO)

C)

How does one become eligible for Part D: Prescription Drug coverage? Must meet certain underwriting guidelines Must have a valid prescription Must have Medicare coverage Must have Medicaid coverage

C)

If a healthcare provider is considered to be a "service provider", what does this mean? Payment for services are always paid on a reimbursement basis Better service is given as compared to a "fee for service" provider Payment for services goes directly to the provider Insured may utilize the services of any provider

C)

Medicare Part A covers outpatient services doctor's fees inpatient hospital stay prescription drugs

C)

The role of the federal government was expanded when Medicaid was established by allowing the state to form a large PPO on a statewide level purchase health insurance from the federal government receive matching funds to expand public assistance programs defer all costs to the federal government for public assistance programs

C)

Which of the following is a legal entity created for the sole purpose of providing affordable group health coverage to its participants? Multiple Employer Welfare Arrangement (MEWA) Multiple Trust Arrangement (MTA) Multiple Purchasing Groups (MPG) Fraternal Benefit Societ

C)

Which statement is TRUE regarding Workers' Compensation coverage Negligence is a factor in determining the employer's liability Workers' Compensation benefits are usually received in a lump sum Employer pays the entire premium for Workers' Compensation coverage The amount received from workers' compensation is usually greater than the employee might receive if he or she sued a negligent employer

C)

Who would be most likely to submit a Medicare Part A claim? State Insured Hospital HICAP

C)

How much does Medicare Part B pay for physician fees? 40% 60% 80% 100%

C) 80%

An accident and health policy that provides reimbursement benefits makes them payable to the provider facility providing service insured insured's spouse

C) insured