Health Providers

Medicaid is intended for:

poverty stricken people

Which of these is NOT considered a supplemental health insuring corporation (HIC) service?

Outpatient medical services. It is considered a basic service. -exceptions include: -foot care services -dental care services -chiropractic care

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

100% of the billed amount. It's due to the physician being outside the network.

How does much Medicare Part B pay for physician fees?

80%. Medicare Part B pays 80% of most doctor's services, outpatient treatments, and durable medical equipment (like oxygen and or wheelchairs).

Part A Hospital expense coverage provided under Medicare is automatically made available to each of the following EXCEPT:

A 70-year old NOT eligible for Social Security. You are eligible to receive Medicare Part A benefits at age 65 or older if you are eligible to receive Social Security benefits. -Exceptions include: -A 50-year old individual who has qualified for SSDI in the last 24 months. -A 55-year old suffering from kidney failure -A 65-year old retire

Which of these preventative care services is NOT provided by health insuring corporation (HIC) primary care physicians?

Adult hearing screenings. -Exceptions include: -Routine examinations -Child immunizations -Well-baby examinations

At what age will a person normally enroll with an insurance carrier under a Part C Medicare Advantage Plan?

At age 65. Most people become eligible got Medicare (and Medicare Supplement policies) when attaining age 65.

Confidentiality of health information (as stated by Ohio HIC laws) applies to information supplied by:

Both by the covered individual and by providers.

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. BUT, at a lower percentage compared to treatment from an in-network provider.

Medicare provides coverage for each of the following EXCEPT:

Custodial Care. It does not cover expense under Medicare. -Exceptions include: -Hospital room and board -doctor and surgeon services -Prescription Drugs

A doctor who accepts Medicare Assignment agrees to which of the following?

Doctor cannot change more than Medicare's scheduled coverage. Medicare pays 80% of this amount and the beneficiary pays 20% after the annual Part B deductible is met. The doctor bills Medicare directly assigning Medicare to pay the doctor for the services rendered.

Medicare Part B covers:

Doctor's charges

A health care provider claim may be settled using which of the following payment methods?

Free-for-service. It is a payment model where services are unbundled ans paid for separately.

Which of these will typically authorize treatment from a specialist?

Gatekeeper. A gatekeeper must authorize treatment from a specialist.

Which of these is a TRUE statement regarding HIC's?

HIC's operate on a prepayment basis. HIC benefits are provided on a Prepaid basis.

Which of the following is NOT taken into consideration when determining eligibility for Medicare benefits?

Income. -Exceptions include: -Chronic Kidney Disease -Age -Social Security Disability

An accident and health policy that provides reimbursement and benefits makes them payable to the...

Insured. An accident and health policy that provides reimbursement benefits makes them payable to the insured. However, the right of assignment is built into most commercial insurance policies that allows policyowners to assign benefits from the insurer directly to the health care provider.

The open enrollment period for Medicare Part B is...

January 1st through March 31

Donna and Marry were racing bicycles in a store parking lot whole 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 inured. Who would most likely be covered under Worker's Compensation?

John. Misconduct on the job where injury occurs wouldn't be covered, however, John was an innocent bystander just doing his job.

Which of the following is Medicare Part B also known as?

Medical Insurance. Medicare Part B covers mostly necessary doctor's services, preventive care, durable medical equipment, hospital outpatient services, laboratory test, x-rays, mental health care, and some home health and ambulance services. You pay a monthly premium for this coverage.

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). A MEWA is an arrangement where a group of employers pool their contributions together to purchase group health and other insurance benefits for their employees. By pooling their contributions together, these smaller employers are better positioned to offer the best benefit packages from insurance companies due to economies of scale. MEWA's are also formed to allow a group of employers to self-insure their healthcare needs.

An example of health insuring corporation (HIC) specialty care provider is a (n):

Neurologist. A general practitioner, family medicine physician, and HIC medical director are not examples.

Paul is an employee who caught a disease unique to the trade in which he was exposed to. Paul has a(n)

Occupational disease

Medicaid is a government-funded program designed to provide health care to:

Poor people.

Which payment of a health claim settlement is typically made directly to the provider of the services?

Prepaid. Prepaid medical service plans (HMO'S) pay providers directly through a process called capitation.

The Federal Employees Benefit Programs consist of two types of health plans for federal civilian employees. The two plans are fee-for-service and:

Prepaid. Two types of plans participate in the FEHB Program: fee-for-service plans and health maintenance organizations (prepaid).

Who provides all preventative and routine medical care given to a health insuring corporation (HIC) member?

Primary care physician. They receive all preventative and routine medical care from the primary care physician.

Which of the following is NOT typically included under "hospital care" for most health insuring corporation (HIC) plans?

Private Duty Nursing -Exceptions include: -Mental Illness Treatment -Diagnostic Lab Services -X-Rays

When comparing an HIC to a PPO, the PPO:

Provides a greater choice of providers. Service may be covered out of network, thereby allowing for greater choice of providers with a PPO.

Which of these is NOT a legal reason for an HIC to release a subscriber's confidential health information?

Public's interest. Under Ohio's law, an HIC may release a subscriber's confidential medical information for any of these reasons EXCEPT "Public interest." -Exceptions include: -Court order -Lawsuit between the subscriber and HIC -Subscriber's consent

The role of the federal government was expanded when Medicaid was established by allowing the state to:

Receive matching funds to expand public assistance programs. Medicaid was created to expand the role of the federal government in health care financing by permitting the state to receive matching funds to expand public assistance programs.

What is Medicare Part B also known as?

Supplementary Medical Insurance

Which of of these do NOT provide primary care to HIC members?

Surgeon. -Exceptions include: -Family medicine physician -Pediatrician -General practitioner

When a preferred provider organization (PPO) insured goes out-of-network, which of the following actions occur?

The insurer will pay a reduced amount. NOT THE INSURED.

An individual can enroll in a Part C medicare Advantage Plan at what time?

When becoming eligible for Medicare. NOT MEDICAID.

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 secondary insurer and pay for claims not fully covered by the group plan. If you are eligible for Medicare because of kidney failure and are also covered by a group health plan, your group plan will pay first on your hospital and medical bills for 30 months. During this time, Medicare pays second.

What type of injury would NOT be covered under a health insurance policy?

Work-related. Work realted would be covered under worker's compensation. -Exceptions included -Accidental -Sports-related -Recreational

Medicare Part A covers:

inpatient hospital stay. Medicare Part A or (Hospital Insurance) covers inpatient care in hospitals and skilled nursing facilities, and it covers care provided in hospice and some care provided at home.