week 10 Health Insurance Essential Quiz
Which percentage of the bill will a patient with Medicare Part B be responsible for after Medicare has paid its portion of the allowable charge?
20 Rationale After 80% of the allowable charge is paid by Medicare, the patient is responsible for the remaining amount. This will be 20% of the allowable charge. Zero percent, 50%, and 80% are incorrect amounts. Text reference: p. 318
A patient on Medicare has met the deductible for the year. Which percentage of the allowable amount billed will be covered by Medicare?
80% Rationale The percentage that Medicare covers after a deductible is met is 80% of the allowable amount. Fifty percent, 75% and 100% are in correct amounts. Text reference: p. 318
Government and managed care organizations have influence over what healthcare providers can charge for services. Which term defines the maximum amount of money that third-party payers will consider to reimburse for a particular procedure?
Allowable amount Rationale The allowable amount is the maximum that third-party payers will consider when calculating reimbursement for a particular procedure. The billable amount is the amount the provider can bill for, and the deductible is the amount the patient must pay out of pocket under a policy before payment for claims bill be considered. Covered benefits are certain health services covered by insurance policies. Text reference: p. 324
Which is a characteristic of independent practice associations?
Are paid for services based on a capitation or fee for services. Rationale Independent practice associations (IPAs) are health maintenance organizations (HMOs) that are paid based on capitations or fee for services and may treat non-HMO patients. Text reference: p. 321
What indicates that the patient has authorized payment of benefits directly to the provider?
Assignment of benefits Rationale The assignment of benefits states that the patient has authorized payment of benefits directly to the provider. Signature on file is a signature a patient makes that indicates claims can be filed on his or her behalf for assignment of benefits. The explanation of benefits is a letter or statement from the insurance carrier describing what was paid, denied, or reduced in payment. It also contains information about amounts applied to the deductible, the patient's coinsurance, and the allowed amounts. A truth in lending form is associated with payment arrangements for accounts. Text reference: p. 321
How are medical procedures that are covered by insurance reimbursed?
At different levels of payment level Rationale Reimbursement is not the same for all insurance companies; depends on the contracted amount. All procedures that are covered by insurance are not reimbursed at the same level of payment. Some policies may pay certain services without a deductible, but others pay after a deductible is met. Insurance providers do not always pay at 100% of usual, customary, and reasonable fees. Text reference: p. 324
How are medical procedures that are recovered by insurance reimbursed?
At different levels of payment level Rationale Reimbursement is not the same for all insurance companies; it depends on the contracted amount. All procedures that are covered by insurance are not reimbursed at the same level of payment. Some policies may pay certain services without a deductible, but others pay after a deductible is met. Insurance providers do no always pay at 100% of usual, customary, and reasonable fees. Text reference: p. 324
A patient who is covered under the Medicare insurance policy benefits from a health maintenance organization (HMO) because of its contract with Medicare. Which Medicare part provides this benefit?
C Rationale Medical Advantage, which is commonly referred to as Medicare Part C provides expanded benefits to patients for a fee through private health insurance programs such as health maintenance organization (HMOs) and participating provider organizations (PPOs) that have contracts with Medicare. Medicare Part A is hospital insurance for Medicare recipients that covers services such as inpatient hospital care, skilled nursing medical insurance for Medicare recipients that covers outpatient care, durable medical equipment, providers' services, and other medical services. Medicare Part D is drug and prescription benefit coverage that Medicare recipients pay a monthly premium for to potentially help lower prescription drug costs and protect against higher future costs. Text reference: p. 318
A patient is a disabled veteran who was honorably discharged from military service. Which insurance program will the patient's spouse and minor children be covered under?
CHAMPVA Rationale CHAMPVA is a health benefits program in which the Department of Veterans Affairs shares the cost of certain healthcare services and supplies with eligible beneficiaries such as a wife or husband and minor children. Medicaid is the federally and state-funded assistance program that provides medical care for needy populations. Medicare is the federal government's health insurance program for people age 65 years and older. TRICARE is healthcare insurance coverage provided by the U.S. Department of Defense for military personnel and their dependents. Text reference: p. 317
Which health insurance policy covers the children of a veteran who died due to service-related disability?
CHAMPVA Rationale Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) provides insurance for the surviving spouses and dependents of veterans who died because of service-related disabilities. TRICARE is the healthcare program for family members of active duty personnel, military retirees and their eligible family members under the age of 65, and survivors of all uniformed services. Medicare is a federal health insurance program that provides healthcare insurance to individuals age 65 years and older, certain individuals below age 65 years with disabilities, and all patients with end-stage renal disease (ESRD). Medicaid is a government program that provides coverage benefits for medically indigent people who meet specific criteria. Text reference: p. 317
How can a medical assistant verify the patient's eligibility and benefits of an insurance policy?
Calling and confirming it with the insurance provider Obtaining confirmation from the insurance provider Web portal Rationale A medical assistant can verify the patient's eligibility and benefits of an insurance policy by calling and confirming it with the insurance provider. This should be followed by obtaining confirmation from the insurance provider about the patient's eligibility from the insurance policy Web portal. A medical assistant cannot verify the patient's eligibility by going through the patient's registration form. A confirmation email of an insurance policy. The eligibility of a patient for an insurance policy cannot be verified by calling the patient, but by calling the insurance provider. A claim-processing manual is used to fill out the insurance claim form. It is not used to verify the eligibility of the patient for the insurance policy. Text reference: p. 325
Which term defines a payment arrangement for healthcare providers?
Capitation Rationale Capitation is a payment method used by many managed care organizations in which a fixed amount of money is reimbursed to the provider for patients enrolled during a specific period of time, no matter what services were received or how many visits were made. Portability policies, and managed care is a type of healthcare. Text reference: p. 315
A person receives benefits under a long-term care insurance plan. Which medical condition does the person likely have?
Cerebral palsy Rationale Long-term care insurance plan provides coverage for the maintenance and medical expenses of people who are chronically ill, disabled, or mentally retarded. Cerebral palsy is a disability that may require long-term care insurance. Gestational diabetes in a condition that pregnant women may experience during pregnancy, so long-term care would not apply. Influenza is not a chronic condition, so that would not qualify for long-term care either. Skin cancer would likely not qualify for long-term care as it can often be treated and is not necessarily a chronic condition. Text reference: p. 326
After a medical procedure, a patient has to pay 20% of the cost, and a third party pays the remainder when the deductible has been met. Which type of policy provision does the patient have?
Coinsurance Rationale Coinsurance is a policy provision that shares the cost of covered losses in a specific ratio, usually 80/20, between the insurance company and the policyholder to the insurance company for which the insurance company agrees to provide certain benefits. A deductible is the amount a policyholder pays per claim towards the total amount of an insured loss before the insurance company begins paying for benefits. A copayment is a predetermined amount that is paid at the time of a medical service. Text reference: p. 316
Which type of insurance plan pays 80% of the charge and the patient pays the remaining 20%?
Coinsurance Rationale When an insurance company pays 80% of the charges and the patient pays 20%, the patient's portion is called coinsurance. Benefits are a list of what it covered under the healthcare plan. The deductible is the amount that a patient must pay out of pocket each time he or she has an encounter with the provider. Text reference: p. 316
A patient who is covered under Medicare obtains prescription drugs with a small copayment. Which Medicare part provides this benefit?
D Rationale Medicare Part D is drug and prescription benefit coverage that Medicare recipients pay a monthly premium for to potentially help lower prescription drug costs and protect against higher future costs. Medicare Part A is hospital insurance for Medicare recipients that covers services such as inpatient hospital care, skill nursing facilities, home healthcare, and hospice services. Medicare Part B is medical insurance for Medicare recipients that covers outpatient care, durable medical equipment, provider's services, and other medical services. Medicare Advantage, which is commonly referred to as Medicare Part C, provides expanded benefits to the patients for a fee through private health insurance programs such as health maintenance (HMOs) and participating provider organizations (PPOs) that have contracts with Medicare. Text reference: p. 317
Which identifies the rem for the amount a policyholder pays out of pocket toward a hospital bill before the insurance company begins paying?
Deductible Rationale A deductible is the amount a policyholder pays per claim toward the total amount of an insured loss before the insurance company begins paying benefits. A premium is the periodic payment of a specific amount by the policyholder to the insurance company for which the insurance company agrees to provide certain benefits. Coinsurance is a policy provision that shares the cost of covered losses in a specific ratio, usually 80/20, between the insurance company and the policyholder. A copayment is a predetermined amount that is paid at the time of a medical service. Text reference: 316
The amount of money that must be paid each year for services before the insurance company begins to pick up the payments in known as what?
Deductible Rationale The deductible is the amount that a patient must pay out of pocket each year before insurance will begin making payments for healthcare services. Benefits are a list of what is covered under a healthcare plan. Funding is the money allocated by the government agencies to cover the cost of the insurance program. The premium is the money paid to the insurance company to be covered by the plan. Text reference: p. 316
The amount of money that must be paid each year for services before the insurance company begins to pick up the payments is known as what?
Deductible Rationale The deductible is the amount that a patient must pay out of pocket each year before insurance will begin making payments for healthcare services. Benefits are a list of what is covered under a healthcare plan. Funding is the money allocated by the government agencies to cover the cost of the insurance program. The premium is the money paid to the insurance company to be covered by the plan. Text reference: p. 316
Which statement is true about Medigap insurance?
Designed to fill "gaps" in coverage left by Medicare Rationale Medigap insurance is designed to fill "gaps" in coverage left by Medicare. Examples are the deductible and copays the patient would be responsible for. Medigap is not mandatory for all patients because it is only applicable to Medicare enrollees. Medigap does not apply to workers' compensation claims. Individuals with a preexisting condition cannot be refused Medigap insurance. Text reference: p. 318
A person is involved in an accident that leaves him unable to work for several months while he recovers. After the accident, the person begins receiving payments to replace his lost income. Which type of insurance does the person have?
Disability Rationale Disability insurance replaces lost income on a weekly or monthly basis to employed policyholders who are unable to work as a result of illness, injury, or disease for reasons other than those covered by workers' compensation. Special risk insurance safeguards a person against loss due to certain diseases, such as tuberculosis or cancer, or certain types of accidents, such as an automobile or airplane crash, up to a maximum benefit. Basic medical insurance pays all or part of a provider's fee for nonsurgical services, including hospital, home, and office visits. A life insurance policy pays out a lump sum of money to a beneficiary at the death of the insured. Text reference: p. 326
Which type of insurance policy replaces lost income due to illness, injury, or disease?
Disability income Rationale Disability insurance replaces lost income on a weekly or monthly basis to employed policyholders who are unable to work as a result of illness, injury, or disease, including psychological disorders, for reasons other than those covered by workers' compensations. Surgical insurance covers all types of surgical procedures, such as incisions, excisions, and the removal of foreign bodies, as well as surgeon and assistant surgeon fees. A life insurance policy pays out a lump sum of money to a beneficiary at the death of the insured. Hospitalization insurance pays for the cost of all or part of the insured person's hospital room and board and specific hospital services, such as the costs involved in having surgery in a hospital. Text reference: p. 326
Which goods or services are covered under Medicare Part B?
Durable medical equipment such as a wheelchair Rationale Durable medical equipment is covered by Part B of Medicare under goods and services. Surgery in a hospital is covered by Part A of Medicare. Dental care and over-the-counter drugs are not covered by Medicare. Text reference: p. 317
Which goods or services are covered under Medicare Part B?
Durable medical equipment such as wheelchair Rationale Durable medical equipment is covered by Part B of Medicare under goods and services. Surgery in a hospital is covered by Part A of Medicare. Dental care and over-the counter drugs are not covered by Medicare. Text reference: p. 317
Which insurance plan reimburses all or part of the costs of services, provided that the charge is usual, customary, and reasonable for that particular service in that part of the country?
Fee for service Rationale Fee for service is insurance that reimburses all or part of the cost of services. Capitation is a payment system in which healthcare service providers are paid a set amount per patient no matter how many times they are seen. TRICARE is health insurance coverage provided by the U.S. Department of Defense for military personnel and their dependents. Managed care is a system of healthcare in which patients agree to visit only providers and hospitals within the defined network to receive the maximum benefits and in which the cost of treatment is monitored by the network. Text reference: p. 321
Which insurance plan reimburses all or part of the costs of services, provided that the charge is usual, customary, and reasonable for the particular service in that part of the country?
Fee for service Rationale Fee for service is insurance that reimburses all or part of services. Capitation is a payment system in which healthcare service providers are paid a set amount per patient no matter how many times they are seen. TRICARE is health insurance coverage provided by the U.S. Department of Defense for military personnel and their dependents. Managed care is a system of health care in which patients agree to visit only providers and hospitals within the defined network to receive the maximum benefits and in which the cost of treatment is . by the network. Text reference: p. 321
A provider from a multispecialty medical group offers treatment to a patient enrolled in a health maintenance organization (HMO) with whom the provider is contracted. Which type of HMO model does the provider belong?
Group model Rationale A group model health maintenance organization (HMO) contracts with a multispecialty medical group to provide healthcare services to the people enrolled in its HMO> A staff model is a type of HMO in which providers are hired to form their own network and they are paid a salary. In an exclusive provider organization (EPO), the plan is "exclusive" in that the employer agrees not to contract with any other HMO plans. In an independent practice association (IPA) HMO model, providers are able to contract with multiple HMOs to provide services to patients. Text reference: p. 321
Am insurance company pays pathology fees for a patient during a follow-up visit. Which type of insurance does the patient have?
Health Rationale Basic health insurance pays all or part of the provider's fee for nonsurgical services, including hospital, home, and office visits. This type of plan may also cover pathology fees, laboratory fees, and diagnostic fees other than costs for surgeries, depending on plan provisions. Surgical insurance covers all types of surgical procedures, such as incisions, excisions, and he removal of foreign bodies, as well as surgeon and assistant surgeon fees. A life insurance policy pays out a lump sum of money to a beneficiary after the death of the insured. Hospitalization insurance pays for the cost of all or part of the insured person's hospital room and board and specific hospital services, such as the costs involved in having surgery in a hospital. Text reference: p. 317
Which services are included in a typical basic medical plan?
Hospitalization Emergency room Diagnostic laboratory fees Preventive health exams Rationale Basic medical insurance typically pays for hospitalization, emergency services, diagnostic fees, and preventive visits. Basic insurance plans do not cover the over-the-counter medications or cosmetic surgery for rhinoplasty; medical spending account funds can often be used for these costs. Text reference: p. 316
A primary care provider (PCP) makes a STAT referral for a patient. How long does a STAT referral take to be approved?
Immediately Rationale A STAT referral is used in emergencies and is typically approved online immediately after it is submitted. An urgent referral is used when the situation is serious but not life-threatening. Urgent referrals are usually approved within 24 hours. A regular referral occurs when a provider refers a patient to a specialist to continue treatment. Regular referrals typically take 3 to 10 working days for approval. Text reference: p. 323
What is the name for an individual group of providers and other healthcare providers who are under contract to provide services to members of different HMOs?
Independent practice association Rationale Independent practice organization is the name associated with a group of providers services to members of different HMOs. Group models contract with a multispecialty medical group to deliver care to their members. Staff models hire providers and pay them a salary. Exclusive provider organization members must choose medical care from network providers, with certain exceptions for emergency or out-of-area services. Text reference: p. 321
What defines a Medigap policy?
Is a shot name for medical supplemental insurance Rationale Medigap is the common name for medical supplemental insurance. Medigap is purchased by the patient and is sold by private insurance companies, not the government. Medigap can only be used to pay the deductible and copays not covered by Medicare. Text reference: p. 318
Which statement is true regarding disability insurance?
It benefits employees suffering from psychological disorders. Rationale Disability insurance replaces lost income on a weekly or monthly basis to employed policyholders who are unable to work as a result of illness, injury, or disease, including psychological disorders, for reasons other than those covered by workers' compensation insurance provides coverage, such as medical costs, rehabilitation costs, and lost wages, for employees who have suffered an injury or illness due specifically to job-related functions. Text reference: p. 326
Which statement is true about TRICARE?
It is available for active duty uniformed service members. Rationale TRICARE includes three plan options and is formally known as CHAMPUS. Active duty service members and their eligible family members are covered under the plan. Text reference: p. 319
Which statements are true regarding regular referrals?
It is necessary when a patient must see a specialist. It takes between 3 and 10 days for review and approval. Rationale A regular referral is used when a primary care provider (PCP) refers a patient to a specialist to continue treatment. It usually takes 3 to 10 days for review and approval. An urgent referral usually takes about 24 hours for approval for a situation that is not life-threatening. A STAT referral is approved by telephone immediately as soon as it is faxed to the utilization review department and is used in an emergency as indicated by the provider. Text reference: p 323
Which type of insurance pays for any loss to a third part caused by the insured person?
Liability Rationale Liability insurance covers any loss to a third part that is caused by the insured person. Liability policies often include benefits for medical expenses resulting from traumatic injuries, lost wages, and pain and suffering. Benefits are payable to those individuals who are injured in the insured's home or car, without regard to the insured's actual legal liability for the accident. A life insurance policy pays out a lump sum of money to a beneficiary at the death of the insured. Disability insurance replaces lost income on a weekly or monthly basis to employed policyholders who are unable to work as a result of illness, injury, or disease for reasons other than those covered by workers' compensation. Special risk insurance safeguards a person against personal loss due to certain diseases, such as tuberculosis or cancer, or certain types of accidents, such as an automobile or airplane crash, up to a maximum benefit. Text reference: p. 326
Which type of insurance pays for any loss to a third party caused by the insured person?
Liability Rationale Liability insurance covers any loss to a third party that is caused by the insured person. Liability policies often include benefits for medical expenses resulting from traumatic injuries, lost wages, and pain and suffering. Benefits are payable to those individuals who are injured in the insured's home or car, without regard to the insured's actual legal money to a beneficiary at the death of the insured. Disability insurance replaces lost income on a weekly or monthly basis to employed policyholders who are unable to work as a result of illness, injury, or disease for reason other than those covered by workers' compensation. Special risk insurance safeguards a person against personal loss due to certain diseases, such as tuberculosis or cancer, or certain types of accidents, such as an automobile or airplane crash, up to a maximum benefit. Text reference: p. 326
A person receives a lump sum amount of money from an insurance company upon the death of a spouse. Which type of insurance did the spouse have?
Life insurance Rationale A life insurance policy pays out a lump sum of money to a beneficiary at the death of the insured. In this example, the spouse who died must have purchased a life insurance policy, providing the beneficiary (i.e., the living spouse) with a lump sum of money at the insured's death. Disability insurance replaces lost income on a weekly or monthly basis to employed policyholders who are unable to work as a result of illness, injury, or disease for reasons other than those covered by workers' compensation. Special risk insurance safeguards a person against loss due to certain diseases up to a maximum benefit. Basic medical insurance pays all or part of a provider's fee for nonsurgical services, including hospital, home, and office visits. Text reference: p. 326
Exclusive provider organizations (EPO), health maintenance organization (HMO), and preferred provider organizations (PPO) are all examples of which type of insurance?
Managed care organizations Rationale Managed care organizations (MCOs) include exclusive provider organizations (EPOs), health maintenance organizations (HMOs), and preferred provider organizations (PPOs). Medicaid, TRICARE, and Medicare are other types of insurance. Test reference: p. 321
Which statement is true regarding managed care?
Managed care reduces patient's out-of-pocket expenses during treatment. Rationale Managed care plans usually require fewer out-of-pocket expenses are less in managed care plans, access to specialized care and referrals can be limited. Treatment options are also limited for providers in managed care plans. In addition, treatment may be delayed because of the increased amount of required paperwork and the need for preauthorizations. Text reference: p. 321
A medical indigent person has an accident and requires medical treatment. Which government insurance plan would provide healthcare coverage for this person?
Medicaid Rationale Medicaid is a government program that provides coverage benefits for medically indigent people who meet specific criteria. Medicare is a federal health insurance program that provides healthcare insurance to individuals age 65 years and older, certain individuals below 65 years with disabilities, or patients with end-stage renal disease (ESRD). TRICARE is the healthcare program for family members of active duty personnel, military retirees and their eligible family members under the age of 65, and survivors of all uniformed services. CHAMPUS, or the Civilian Health and Medical Program of the Uniformed Services, was the healthcare program for family members of active duty personnel, military retirees and their eligible family members under the age of 65, and survivors of all uniformed services prior to TRICARE. Text reference: p. 318
What is the federally and state-funded assistance program that provides medical care for the indigent?
Medicaid Rationale Medicaid is the federally and state-funded assistance program that provides medical care for the indigent. Medicare is the federal government's health insurance program for people age 65 years and older. TRICARE is health insurance coverage provided by the U.S. Government of Defense for the military personnel and their dependents. CHAMPVA is a health benefits program in which the Department of Veterans Affairs shares the cost of certain healthcare services and supplies with eligible beneficiaries. Text reference: p. 318
A person receiving Supplemental Security Income (SSI) has an accident and files a claim under his government insurance plan for medical expenses. Which type of government insurance plan does he have?
Medicaid Rationale Medicaid provides healthcare benefits to people who receive Supplemental Security Income (SSI). TRICARE is the healthcare program for family members of active duty personnel, military retirees and their eligible family members under the age of 65, and survivors of all uniformed services. Medicare is a federal health insurance program that provides healthcare insurance to individuals age 65 year and older, certain individuals below age 65 years with disabilities, and all patients with end-stage renal disease (ESRD). Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) provides insurance for the surviving spouses and dependents of veteran who died because of service-related disabilities. Text reference: p. 318
Which programs provide healthcare benefits for a patient who cannot afford treatment?
Medicaid Medicare Rationale Medicaid provides coverage benefits for medically indigent people. Medicare covers all healthcare benefits for individuals who are age 65 and older and also individuals with certain disabilities who are younger than age 65. TRICARE is the government insurance plan that provides healthcare coverage for dependents of military personnel. Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) provides insurance for dependents of veterans who died in service. Indemnity plans are traditional health insurance plans, which enable the policyholder to pay for all or a share of the cost of the expenses. This happen regardless of which provider, hospital, or insurance plan is used. Text reference: p. 317-318
A serious ill patient is hospitalized in an emergency unit. After treatment, the patient paid a certain amount of the hospital bill, and the remaining cost was covered by insurance. Which insurance plan does the patient hold?
Medical Rationale The patient holds major medical insurance, which provides coverage to an insured person during severe illness and hospitalization. Major medical plans usually have a set amount, or deductible, for which the patient is responsible. Once that is paid, the plan covers most of the remaining cost of care, subject to copays or coinsurance paid by the patient. Disability insurance does not pay any hospitalization charges, but it does pay for disability due to accident and illness. Special risk insurance covers certain diseases, such as cancer, and accidents, but it does not cover the hospitalization charges for severe illness. Life insurance provides the beneficiary a lump sum amount of money upon the death of the policyholder; it does not pay the hospitalization charges of a person. Text reference: p. 316
A 30-year-old patient is diagnosed with end-stage renal disease (ESRD) and is unable to work. Which program offers healthcare benefits for this patient?
Medicare Rationale Medicare is a federal health insurance program that provides healthcare insurance to individuals age 65 and older, certain individuals below age 65 years with disabilities, and all patients with end-stage renal disease (ESRD). TRICARE is the healthcare program for family members under the age of 65, and survivors of all uniformed services. Medicaid is a government program that provides coverage benefits for medically indigent people who meet specific criteria. Worker's compensation insurance protects workers who have experienced a loss of wages resulting from an occupational accident or disease that was not a result of negligence. Text reference: p. 317
Which government plan provides healthcare coverage for a 70-year-old patient who has suffered a heart attack?
Medicare Rationale Medicare is a federal health insurance program that provides healthcare insurance to individuals age 65 years and older, and certain individuals below age 65 years with disabilities and end-stage renal disease (ESRD). TRICARE is the healthcare program for family members of active duty personnel, military retirees and their eligible family members under the age of 65, and survivors of all uniformed services. Medicaid is a government program that provides coverage benefits for medically indigent people that meet specific criteria. Civilian Health and Medical program of the Department of Veterans Affairs (CHAMPVA) provides insurance for the surviving spouses and dependents of veterans who died because of service-related disabilities. Text reference: p. 317
Which federally funded health insurance program provides coverage for individuals 65 years of age or older?
Medicare Rationale Medicare is a federally funded insurance that provides coverage to individuals 65 years of age or older. TRICARE is for dependents of military personnel. Medicaid is a federally funded program that provides for medically indigent people. CHAMPVA covers surviving spouses and dependent children of veterans who died as a result of service-related disabilities. Text reference: p. 317
Which is the federal government's health insurance program for people age 65 years or older?
Medicare Rationale The federal government's health insurance program for people age 65 years and older is known as Medicare. TRICARE is health insurance coverage provided by the U>S> Department of Defense for military personnel and their dependents. Medicaid in the United States is a social healthcare program for families and individuals with low income and resources. CHAMPVA is a health benefits program in which the Department of Veterans Affairs shares the cost of certain healthcare services and supplies with eligible beneficiaries. Text reference: p. 317
A patient is enrolled in Medicare. Which part has the greater cost?
Medicare Part B Rationale The patient must pay a premium for enrollment in Medicare Part A because it is financed with contributions deducted from employed individuals' salaries and with matching contributions from their employers. Text reference: p. 317
A person who is eligible for Social Security benefits is automatically enrolled into which insurance plan?
Medicare part A Rationale A person eligible for Social Security benefits is automatically enrolled in Medicare Part A. Those enrolled in Part are eligible for Part B, but they must apply for these benefits. Text reference: p. 317
Which statement is true when a patient participates in a health maintenance organization (HMO)?
Must use HMO providers to receive covered care. Rationale A person who participates in an HMO must see providers who are contracted with the HMO and will not be covered if the person sees a provider outside the HMO. There is no limit on how many visits the patient in an HMO may make to the provider, and there is no deductible applied to HMO policies, although there may be a copay. Text reference: p. 321
Who may qualify for Medical services?
People older than the age of 65 years who are retired from the Civil Service. Rationale Medicare is a federal program for the following categories: people older than the age of 65 years who are on Social Security, who are retired from the railroad or Civil Service, disabled workers at an age, children and adults who have chronic kidney disease, and kidney donors at any age. Text reference: p. 317
All insurance must be paid for. What is the term for the payment that the patient makes to the insurance company to be covered?
Premium Rationale The payment to the insurance company is called the premium. Benefits are a list of what is covered under the healthcare plan. Funding is the money allocated by the government agencies to cover the cost of the insurance program. A deductible is the amount of money that must be paid out of pocket before the insurance begins paying for services provided. Text reference: p. 316
Which statement is true regarding group policies?
Premiums are paid through payroll deductions. Rationale The premium for a group policy is generally deducted from employee salaries. Unlike an individual policy, a group policy provides higher benefits with loser premiums are collected. Physical examinations are generally not required to obtain insurance benefits under a group policy, and a group policy does not check for any of the individuals' preexisting conditions. Text reference: p. 319
Who receives the payment when the patient signs for "assignment of benefits"?
Provider Rationale Assignment of benefits means that the insurance payment will go directly to the provider and be credited to the patient's account. Neither the patient nor his or her designated family member will receive the insurance payment. The patient will still owe a copayment even if the assignment of benefits is signed. Text reference: p. 321
Which service is covered my Medicare Part B?
Provider's services Rationale Medicare Part B is medical insurance for Medicare recipients that covers outpatient care, durable medical equipment, provider's services, and other medical services. Medicare Part A is hospital insurance for Medicare recipients that covers services such as inpatient hospital care, skilled nursing facilities, home healthcare, and hospice services. Text reference: p. 317
What identifies a fee schedule based on provider network, liability expense, and overhead?
Resource-based relative value system (RBVS) Rationale The RBBS is a fee schedule based on provider network, liability expense, and overhead. MCOs provide types of insurance. Medicare reimbursement is money paid to the medical facility for services. The explanation of benefits is a letter or statement from the insurance carrier describing what was paid, denied, or reduced in payment. It also contains information about amount applied to the deductible, the patient's coinsurance, and the allowed amounts. Text reference: p. 318
A company offers an insurance policy that is administered by a third party to its employees, but the employee's healthcare costs are paid by the company. Which type of insurance policy is the company offering to its employees?
Self-insured plan Rationale In a self-insured plan, either an employer provides health or disability benefits to employees with its own funds, or the employees pay for health coverage with their own personal funds. Usually, a third-party administrator (TPA) handles the paperwork and claim payments for a self-insured group. In a group policy, the cost of the healthcare services is usually shared by the employee through payroll deduction. The company does not pay for the healthcare costs. In an individual policy, the insured pays the premiums directly to the insurance company that issued the policy. Government plans are entitlement programs or healthcare plans for individuals that are sponsored and/or subsidized by the state or federal government, such as Medicaid, Medicare, and TRICARE. Text reference: p. 320
Which type of health insurance is most often utilized by a company that is large enough to pay expensive medical services for its employees?
Self-insured plans Rationale Employers that are large enough to pay for employees' medical services would be most likely to utilize self-insured plans. Group policies are purchased and subsidized by an employer to cover a number of people under a single contract to provide greater benefits at a lower premium due to the large pool of people from whom premiums are collected. Individual policies are for individuals who do not qualify for inclusion in a group or government-sponsored plan. Government plans are entitlement programs or healthcare plans for individuals that are sponsored and/or subsidized by the state or federal government, such as Medicaid, Medicare, and TRICARE. Text reference: p. 319
Under Medicare Part A, which goods or services would be covered?
Services in a hospital on an inpatient basis Rationale Medicare Part A covers services provided in a hospital and on an inpatient basis. Canes and walkers purchased in a pharmacy are covered by Medicare Part D. Physical therapy treatments and medication administered in the medical office are covered by Medicare Part B. Text reference: p. 317
Which type of insurance will pay a maximum benefit to a patient who is diagnosed with pancreatic cancer?
Special risk Rationale Special risk insurance safeguards a person against loss due to certain diseases, such as tuberculosis or cancer, or certain types of accidents, such as an automobile or airplane crash, up to a maximum benefit. Surgical insurance covers all types of surgical procedures, such as incisions, excisions, and the removal of foreign bodies, as well as surgeon and assistant surgeons fees. A life insurance policy pays out a lump sum of money to a beneficiary at the death of the insured. Hospitalization insurance pays for the cost of all or part of the insured person's hospital room and board and specific hospital services, such as the costs involved in having surgery in a hospital. Text reference: p. 326
A provider works for a network owned by a health maintenance organization (HMO) and is paid a salary. Which type of HMO model does the provider work for?
Staff model Rationale In a staff model, a health maintenance organization (HMO) owns the network, hires the providers, and pays them a salary instead of contracting with them to form a network. A group model HMO contracts with a multispecialty group to provide care and pays the provider's group as a whole using capitation or a fee for service billing model. The provider's group is then responsible for paying their provider members. Exclusive provider organizations (EPO) receive a fixed fee for providing patient services. Independent practice associations (IPA) also receive payments through capitation or fee for service billing model. Text reference: p. 317
A person purchases an insurance package with all insurance benefits except for basic medical care. Which fee(s) will the insurance package cover for a tonsillectomy?
Surgeon's fee Assistant surgeon's fee Maximum amount per day of hospital care Rationale A tonsillectomy is a surgical procedure, which involves the excision of body parts. Since the insurance package purchased includes surgical and hospitalization benefits and a tonsillectomy is a surgery, the surgeon's fee and the assistant surgeon's fee would both be reimbursed through surgical insurance. The maximum amount per day for hospital care is also reimbursed through hospital insurance. Radiology fees are usually covered under a basic medical plan as a nonsurgical service and would not be covered by this insurance package. A deductible is a specific amount of money, usually ranging from $100-$500, that a patient must pay out of pocket on a yearly or per-incident basis before the insurance carrier begins paying. Text reference: p. 316
A patient undergoes surgery for kidney stones in a hospital. Which type(s) of insurance would cover this procedure?
Surgical Basic medical Hospitalization Rationale Surgical insurance covers all types of surgical procedures, such as incisions, excisions, and the removal of foreign bodies, as well as surgeon and assistant surgeon fees. Hospitalization insurance pays for the cost of all or part of the insured person's hospital room and board and specific hospital services, such as the costs involved in having surgery in a hospital. Basic medical covers pathology fees, lab fees, and other diagnostic fees that may incurred as a result of the person's hospitalization and are not covered under surgical or hospitalization insurance. Disability insurance replaces lost income on a weekly or monthly basis to employed policyholders who are unable to work as a result of illness, injury, or disease for reasons other than those covered by workers' compensation. A life insurance policy pays out a lump sum of money to beneficiary at the death of the insured. Text reference: p. 316
Which federally funded insurance covers dependents of military personnel who receive treatment from civilian providers at the expense of the government?
TRICARE Rationale TRICARE is for dependents of military personnel. Medicare is a federally funded insurance that provides coverage to individuals 65 years of age or older. Medicaid is federally funded insurance to provide for medically indigent people. CHAMPVA covers surviving spouses and dependent children of veterans who died as a result of service-related disabilities. Text reference: p. 317
The spouse of military personnel is undergoing heart surgery. Which government insurance plan covers the spouse's treatment?
TRICARE Rationale TRICARE is the healthcare program for family members of active duty personnel, military retirees and their eligible family members under the age of 65, and survivors of all uniformed services. Medicaid is a government program that provides coverage benefits for medically indigent people who meet specific criteria. Medicare Part A is hospital insurance for Medicare recipients that covers services such as inpatient hospital care, skilled nursing facilities, home healthcare, and hospice services. Medicare Part B is medical insurance for Medicare recipients that covers outpatient care, durable medical equipment, providers' services, and other medical services. Text reference: p. 317
Why does the medical assistant (MA) ask for the patient's health insurance information when he or she calls to schedule an appointment?
The MA can then verify the insurance and let the patient know his or her out-of-pocket expenses, or copayment. Rationale The MA will request the patient's health insurance and let the patient be aware of any out-of-pocket expenses. Insurance verification does not ensure the doctor will be paid if the services are not covered. Rules of the office are important, but that is not the most important reason. Scheduling appointments is typically not based on whether the patient has insurance. Patients can be given an estimate of expected charges and be required to pay for services rendered of the date of service when they are uninsured. Text reference: p. 324
What is the name for the committee that reviews patient care and testing to determine medical necessity?
Utilization review Rationale A utilization review committee reviews individual cases to make certain that medical care services are medically necessary (the specificity of diagnosis coding is critical) and to study how providers use medical care resources. A fee schedule lists fees services. A third-party payer is an insurance company, and authorizations are used to file insurance and release information to insurance companies or other individuals involved in the patient's care. Text reference: p. 323
An individual has insurance that covers medical expenses for laser eye surgery. Which type of coverage does the person have?
Vision care Rationale Vision care insurance covers all or a percentage of the cost for refraction, lenses, and frames. Some vision plans also pay for corrective procedures, including laser eye surgery, depending on plan provisions. Dental care insurance covers certain dental expenses of the patient. Special risk insurance safeguards a person against loss due to certain diseases, such as tuberculosis or cancer, or certain types of accidents, such as an automobile or airplane crash, up to a maximum benefit. A life insurance policy pays out a lump sum of money to a beneficiary at the death of the insured. Text reference: p. 316
Which term describes what managed healthcare plans require from the patient at the time of each visit at the provider's office?
copayment Rationale The copayment is required at the time of the visit at the provider's office. The premium is the payment required to have the insurance benefit. The deductible is a set amount of money the patient has to pay before the insurance company begins to pay. Exclusions are limitations on the insurance contract for which benefits are not payable. Text reference: p. 316
