Online Course Questions: Health
A policyholder has a major medical plan with a 80%/20% coinsurance and a deductible of $75. If the insured has previously met her deductible and receives a bill for $175, how much will the insurer pay? $35 $75 $100 $140
$140
Kate has a Major Medical Plan with a 75/25 coinsurance and a deductible of $25. How much will she have to pay if she, not having met any of her deductible, visits the doctor and receives a bill for $125? $25.00 $50.00 $75.00 $100.00
$50
Kim has health insurance with a deductible of $500 and an 80/20 coinsurance. How much will she pay if she incurs a loss of $1,500? $200 $500 $700 $1,300
$700
The typical long-term care insurance policy is designed to provide a minimum of __ year(s) of coverage. 1 3 5 7
1
Social Security disability income benefits are payable to individuals who sustain disabilities which are expected to result in death, or last at least: 1 month 3 months 6 months 12 months
12 months
The waiting period before qualifying for Social Security disability benefits is how many months? 3 5 6 12
5
What percentage of a participant's income are group long-term disability benefit amounts typically limited to? 30% 40% 50% 60%
60%
HIPAA considers which of the following as "individually identifiable health information"? A person's employment history A person's net income A person's hire date A person's health claim information
A person's health claim information
Under a disability income policy, which provision would be payable if the cause of an injury is unexpected and accidental? Presumptive disability provision Absolute accidental provision Accidental death benefit provision Accidental bodily injury provision
Accidental bodily injury provision
Under the misstatement of age provision in a health insurance policy, what can a company do if it discovers that an insured gave a wrong age at the time of application? Cancel the policy Increase the premium Adjust the benefits Assess a penalty
Adjust the benefits
In health insurance policies, a waiver of premium provision keeps the coverage in force without premium payments Whenever an insured is unable to work During the time an insured is confined in a hospital Following an accidental injury, but not during sickness After an insured has become totally disabled as defined in the policy
After an insured has become totally disabled as defined in the policy
The waiver of premium does NOT include which provision? All future premiums are waived if the insured recovers from the disability If the insured qualifies, the premiums are waived retroactively to the beginning of the disability The waiver of premium generally does not extend past the insured's age 60 or 65 To qualify for the exemption, the insured must experience total disability for more than a specified period
All future premiums are waived if the insured recovers from the disability
Which situation would qualify an individual for receiving benefits from a qualified long-term care policy? Becoming unemployed Becoming temporarily disabled Becoming injured on the job Becoming cognitively impaired (mentally ill)
Becoming cognitively impaired (mentally ill)
Which type of business insurance is meant to cover the costs of continuing to do business while the owner is disabled? Disability overhead policy Business continuation policy Disability buy-sell policy Business overhead expense policy
Business overhead expense policy
When an insured changes to a more hazardous occupation, which disability policy provision allows an insurer to adjust policy benefits and rates? Relation of earnings to insurance provision Change of occupation provision Conformity of state statutes provision Modified occupation provision
Change of occupation provision
Which of the following statements is NOT true regarding a Critical Illness Plan? Pays a lump sum to the insured upon the diagnosis of a critical illness The insurer may have a list of critical illnesses they will cover Coverage is limited to a single devastating disease Also known as Specified Disease Plans
Coverage is limited to a single devastating disease
In group health care, what is the purpose of the coordination of benefits provision? Determines where an insured goes to receive treatment Determines what is paid by the primary and secondary insurers in the event of a claim Ensures that a health provider receives the proper benefit amount owed Determines which parent's plan covers a dependent child
Determines what is paid by the primary and secondary insurers in the event of a claim
Which of the following statements about long-term care insurance policies is NOT correct? Maximum coverage periods generally extend from 2 to 6 years. Long-term care policies sold today must be guaranteed renewable. A long-term care policy with a long probationary period will have a lower premium than one with a shorter probationary period. Drug and alcohol dependency is included in most long-term care insurance policies.
Drug and alcohol dependency is included in most long-term care insurance policies.
Which section of a health insurance policy specifies the conditions, times, and circumstances under which the insured is NOT covered by the policy? Coinsurance provision Coverages Insuring clause Exclusions
EXCLUSIONS
An insurance company needs to obtain personal information from a third party concerning an applicant. Which law do all insurers and their producers need to comply with? USA Patriot Act Personal Information Act Fair Credit Reporting Act McCarran-Ferguson Act
Fair Credit Reporting Act
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
Falling below the federal poverty level
Which of these will typically authorize treatment from a specialist? Administrator Policyowner Insurance company Gatekeeper
Gatekeeper
How is Medicare Part B funded? Employer taxes Payroll taxes User premiums General tax revenue and user premiums
General tax revenue and user premiums
Which type of coverage pays an amount per day for hospitalization directly to the insured regardless of the insured's other health insurance? MEWA Mutual Group Hospital indemnity
Hospital indemnity
Which of the following best describes the characteristics of Preferred Provider Organizations (PPOs)? PPOs operate like an HMO on a prepaid basis If service is obtained outside the PPO, benefits are reduced and costs increase PPOs are generally public in nature rather than private Health care providers themselves are barred from forming a PPO due to conflict of interest
If service is obtained outside the PPO, benefits are reduced and costs increase
What does the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 allow an employee to do? In the event of employment termination, group health insurance can be kept if the employee pays the premiums Receive a tax credit to help offset the cost of health insurance Remain on their current coverage for 30 months In the event of employment termination, group health insurance can be kept if the employer pays the premiums
In the event of employment termination, group health insurance can be kept if the employee pays the premiums
Which of the following statements pertaining to Medicaid is NOT correct? It provides federal matching funds to states for medical public assistance plans. Its purpose is to help eligible needy persons with medical assistance. Medicaid benefits may be used to pay the deductible and coinsurance amounts of Medicare. It limits financial assistance to persons age 65 or over who are in need of medical services they cannot afford.
It limits financial assistance to persons age 65 or over who are in need of medical services they cannot afford.
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
January 1 through March 31
Which of the following is considered to be a point of service (POS) plan? Preferred provider organization Managed care plan Protected care provider Restricted provider organization
Managed care plan
Which of the following statements about long-term care insurance policies is NOT correct? Maximum coverage periods generally extend from 2 to 6 years. Long-term care policies sold today must be guaranteed renewable. A long-term care policy with a long probationary period will have a lower premium than one with a shorter probationary period. Drug and alcohol dependency is included in most long-term care insurance policies.
Medicare Part A is automatically provided when a qualified individual applies for Social Security benefits.
Which of these gaps in Medicare coverage is addressed with Medicare Supplemental Insurance? Medicare in-hospital deductible Dental work Nutritional supplements Chiropractic care
Medicare in-hospital deductible
Which type of plan would be most appropriate for an individual on Medicare and concerned that Medicare will NOT pay for charges exceeding the approved amount? Medicaid Long-term care Medicare supplement Plan F Comprehensive major medical
Medicare supplement Plan F
Under which criteria may a group health plan exclude participation? Member's claims history Member's current age Member's pre-existing condition Member's part-time employment status
Member's part-time employment status
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
Must have Medicare coverage
When an insured has a major medical plan with first dollar coverage, how does this impact the benefits paid? No deductible payment is required Deductible specified in the contract is payable by the insured Insured must pay a percentage of covered losses An initial deductible plus a percentage of the remaining covered loss is owed by the insured
No deductible payment is required
When a group of doctors and hospitals in a designated area contract with an insurer to provide health care at a prearranged figure to the insured, the arrangement is known as
PPO
Which of the following is typically NOT eligible for coverage in a group health policy? Full-time employee Temporary employee Business owner Partner in a partnership
Temporary employee
The principal purpose of the Medicaid program is to assist in providing medical care to persons who are Not covered by Medicare Over the age of 65 Unable to afford the medical care they need Not covered by any individual insurance plan
Unable to afford the medical care they need
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
When becoming eligible for Medicare
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
age 65
With regard to an HMO, the term capitation refers to the premium for the HMO coverage value of the HMO capital improvements amount of capital the HMO possesses amount paid to the physician for each member
amount paid to the physician for each member
Which type of health plan normally covers ONLY the services of approved providers? An HMO plan A PPO plan A POS plan A managed indemnity plan
an HMO plan
Medical Expense Insurance would cover an injury occurring at the insured's residence an injury occurring at work an injury caused by war elective surgeries
an injury occurring at the insured's residence
The factor used most often when underwriting a disability income policy is annual earnings sex of the insured marital status occupation
annual earnings
Bill requires some nursing care and supervision but NOT full-time care. Which of these nursing home options would best serve him? Nursing home Assisted living Congregate housing Custodial residence
assisted living
A disability income policy can prevent an insured from earning a higher income than if he/she were working by utilizing elimination periods probationary periods benefit limits deductibles
benefit limits
The type of policy where the insurer can send a notice to the insured that the policy has been cancelled in the middle of the term is called noncancelable conditionally renewable optionally renewable cancelable
cancelable
What is issued to each employee of an employer health plan? Provision Receipt Policy Certificate
certificate
In which of the following processes will the insurer oversee the insured's hospital stay to confirm everything is going according to schedule and that the insured will be released as planned? Pre-certification review Pretense review Congruent review Concurrent review
concurrent review
A health insurance policy where the insurer has the right to terminate the policy for reasons other than the insured's health is called limited renewable conditionally renewable guaranteed renewable conditionally cancelable
conditionally renewable
Which type of treatment is considered a major service in an indemnity dental plan? Diagnostic X-rays Restorative fillings Teeth cleaning Dentures
dentures
Medicare Part B covers long-term care hospital room and board doctor's charges prescription drugs
doctors charges
Benefits provided by a Medicare Supplement policy must NOT be payable to the insured duplicate Medicare benefits be sold to individuals under 70 charge additional premiums
duplicate medicare benefits
Coverage under a cancelable health insurance policy may be terminated by The insurer only the insured only Either the insured or the insurer An arbitration committee
either the insured or the insurer
According to the Affordable Care Act, a grandfathered group health plan MUST cover pediatric oral and vision care preventative services at no cost to the insured essential health benefits with no lifetime dollar limits emergency services provided by a non-participating provider
essential health benefits with no lifetime dollar limits
After an insured gives notice of loss, what must he/she do if the insurer does not furnish forms? File a lawsuit Contact the insurer again requesting forms Nothing File written proof of loss
file written proof of loss
Which of these statements about Medicaid is CORRECT? Pays for Medicare charges exceeding the approved amount Intended for senior citizens Funded by federal, state, and local taxes Administered by the Federal government
funded by federal, state, and local taxes
A health insurance policy that allows an insurer to change the policyowner's premiums, but NOT cancel the policy is called a(n) guaranteed renewable policy conditionally renewable policy optionally renewable policy noncancelable policy
guaranteed renewable policy
Which type of long-term care benefit would be most appropriate for a stroke victim who requires speech therapy administered at her home? Respite care Continuing care Home health care Custodial care
home health care
Which of the following is NOT taken into consideration when determining eligibility for Medicare benefits? Chronic kidney disease Income Age Social Security disability
income
Which of the following types of deductibles would apply a single deductible to both medical and dental insurance coverage? Standard deductible Combined deductible Integrated deductible Blended deductible
integrated deductible
A person covered with an individual health plan is issued a policy is issued a certificate of medical costs does not contract directly with the insurance company is not subject to medical underwriting
is issued a policy
The time limit for filing claim disputes is addressed in which provision of an accident and health policy? Legal actions Entire contract Time of payment of claims Payment of claims
legal actions
Someone needing custodial care at home would require which type of coverage? Major medical Disability Long-term care Medicaid
long term care
Coming from an insurance point of view, which of the following is the main risk associated with disability? Loss of limbs Loss of income Decreased work skills Decreased mobility
loss of income
The reinstatement provision in a health insurance policy is mandatory optional voluntary discretionary
mandatory
A company may change the wording of a uniform policy provision in its health insurance policies only if the company's board of directors approves the change modified provision is not less favorable to the insurer applicant directs that it be changed modified provision is not less favorable to the insured
modified provision is not less favorable to the insured
What type of health insurance policy may NOT be changed in any way by the insurer, up to a specified age, so long as the premiums are paid? Guaranteed renewable Noncancellable Conditionally renewable Optionally renewable
noncancelable
Which of the following types of health insurance policies prevents the company from changing the premium rate or modifying the coverage in any way? Optionally renewable Noncancellable Guaranteed renewable Cancellable
noncancellable
How are premiums paid by the insured for personally owned disability income insurance treated for tax purposes? partially tax deductible not tax deductible fully tax deductible tax deferred
not tax deductible
Which of these characteristics of an applicant is NOT taken into consideration when assessing risk for Disability coverage? health of applicant gender of applicant number of children occupation of applicant
number of children
A clause that allows an insurer the right to terminate coverage at any anniversary date is called a(n) conditionally renewability clause optional renewability clause selective renewability clause cancelable clause
optional renewability clause
States that have "no loss no gain" laws require a replacing policy to keep the same type of coverage as the policy it replaces not charge a different premium from the policy it replaces pay for half of any ongoing claims under the policy it replaces pay for ongoing claims under the policy it replaces
pay for ongoing claims under the policy it replaces
Which of these factors is NOT taken into consideration when determining the cost of a long-term care policy? Health of applicant Amount of benefits provided Age of applicant Personal income
personal income
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
poor people
Medicaid is intended for people with kidney failure people aged 65 and older unemployed people poverty stricken people
poverty stricken people
Which of the following does Medicare Part D cover? Intensive care coverage Doctor visits Prescription drugs Hospital coverage
prescription drugs
A health insurance policy will typically cover injuries obtained from war elective cosmetic surgery preventative health services work related injuries
preventative health services
HMOs are known for stressing preventive medicine and early treatment state-sponsored health care plans in-hospital care and services health care services for government employees
preventive medicine and early treatment
Who is the individual paid on a fee-for-service basis? Subscriber Administrator Insured Provider
provider
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
receive matching funds to expand public assistance programs
Continuous 24-hour care provided by licensed medical professionals under the direct supervision of a physician is called adult day care home health care skilled nursing care custodial care
skilled nursing care
Typically, Long-Term Disability benefits are coordinated with which benefit plan? Social Security Individual Retirement Account Life insurance Accrued sick time
social secuirty
An individual covered under a Blue Cross Blue Shield plan is called a(n) participant subscriber policyowner insured
subscriber
Justin is receiving disability income benefits from a group policy paid for by his employer. How are these benefits treated for tax purposes? Partially taxable income Non-taxable income Taxable income Conditionally taxable income
taxable income
This MANDATORY health policy provision states that the policy, including endorsements and attached papers, constitutes the partial insurance contract between the parties the entire insurance contract between the parties the conformity of state statutes the legal purpose of the contract
the entire insurance contract between the parties
A disability elimination period is best described as a time deductible dollar deductible eligibility period probation period
time deductible
If a patient with a preferred provider organization (PPO) chooses to use a non-PPO, the patient usually can expect To have higher out-of-pocket expenses To pay the full cost of care 100% reimbursement for the service provided A one year waiting period before re-enrolling in the PPO
to have higher out of pocket expenses
All of the following are reasons that the government provides insurance EXCEPT To meet social needs To reduce fraudulent claims To make insurance available for certain groups To encourage economic development
to reduce fraudulent claims
Craig submits a $500 claim for medical expenses. With a past due premium of $100, the insurer pays $400. Which of the Uniform Optional Provisions covers this situation? Payment of claims Legal actions Unpaid premium Time of payment of claims
unpaid premium
What is the primary factor that determines the benefits paid under a disability income policy? Education level Wages Type of occupation Age
wages
When are group disability benefits considered to be tax-free to the insured? When the recipient pays the premiums When the employer pays the premiums When both the employer and recipient pay the premiums When benefits paid are equal to or lower than the recipient's salary
when the recipient pays the premiums
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 Will not pay for any of the covered expenses Will be the primary insurer and the group plan will be secondary
will be the secondary insurer and pay for claims not fully covered by the group plan
