CH: 10 Medical Plans

Which of the following individuals will be eligible for coverage on the Health Insurance Marketplace? A A permanent resident lawfully present in the U.S. B Someone who has Medicare coverage C A U.S. citizen who is incarcerated D A U.S. citizen living abroad

A A permanent resident lawfully present in the U.S.

The purpose of managed care health insurance plans is to A Control health insurance claims expenses. B Provide for the continuation of coverage when an employee leaves the plan. C Provide access to the largest number of physicians as possible. D Coordinate benefits.

A Control health insurance claims expenses.

When is the annual open enrollment for state insurance exchanges? A November 1 through January 31 B December 1 through December 31 C January 1 through February 28 D December 1 through March 1

A November 1 through January 31

An applicant has a history of heart disease in his family, so he would like to buy a health insurance policy that strictly covers heart disease. What type of policy is this? A Specified coverage B Single indemnity protection C Term health coverage D Comprehensive care coverage

A Specified coverage

What is the maximum age for qualifying for a catastrophic plan? A 26 B 30 C 45 D 62

B 30

Adopting parents must inform their insurer that a child has been added to the family within A 60 days. B 31 days. C 30 days. D 1 year.

B 31 days.

Which of the following hospice expenses would NOT be covered in a cost-containment setting? A Special hospital bed B Antibiotics C Tylenol D Morphine

B Antibiotics

Health insurance policies providing maternity benefits must also provide coverage for postpartum inpatient hospital care. How much coverage must be provided for delivery by Caesarean section? A No more than 1 week B At least 96 hours C At least 1 week D No more than 48 hours

B At least 96 hours

When an insurer offers services like preadmission testing, second opinions regarding surgery, and preventative care, which term would best apply? A Claims discrimination B Case management provision C Cost reduction D Claims reduction

B Case management provision

An insured is receiving hospice care. His insurer will pay for painkillers but not for an operation to reduce the size of a tumor. What term best fits this arrangement? A Claims Saving B Cost-containment C Selective Coverage D Limited Coverage

B Cost-containment

The Patient Protection and Affordable Care Act includes all of the following provisions EXCEPT A Coverage for preventive benefits. B Individual tax deduction for premiums paid. C Right to appeal. D No lifetime dollar limits.

B Individual tax deduction for premiums paid.

Which of the following is NOT a metal level of coverage offered under the Patient Protection and Affordable Care Act? A Bronze B Iron C Gold D Silver

B Iron

What term is used to describe when a medical caregiver contracts with a health organization to provide services to its members or subscribers, but retains the right to treat patients who are not members or subscribers? A Indemnity contract B Open panel C Closed panel D Restrictive rights

B Open panel

When health care insurers negotiate contracts with health care providers or physicians to provide health care services for subscribers at a favorable cost, it is called A Point of Service Plans (POS). B Preferred Provider Organization (PPO). C Managed care. D Indemnity plans.

B Preferred Provider Organization (PPO).

Who chooses a primary care physician in an HMO? A A referral physician B The individual member C HMO subscribers do not have a primary care physician D The insurer

B The individual member

Under HIPAA, which of the following is INCORRECT regarding eligibility requirements for conversion to an individual policy? A An individual who doesn't qualify for Medicare may be eligible. B The gap of coverage for eligibility is a period of 63 or less days. C An individual who was previously covered by group health insurance for 6 months is eligible. D An individual who has used up COBRA continuation coverage is eligible.

C An individual who was previously covered by group health insurance for 6 months is eligible.

Bob purchased a policy to provide coverage on himself, his wife Linda, and their two children, John and Kristen. All of them would need to prove insurability EXCEPT A Linda. B John and Kristen. C Any children born to them after the inception of the contract. D Bob.

C Any children born to them after the inception of the contract.

What term is used to describe when the medical caregiver provides services to only members or subscribers of a health organization, and contractually is not allowed to treat other patients? A Probationary B Open panel C Closed panel D Corridor

C Closed panel

As deductible amounts increase, premium amounts change in what way? A Remain the same. Changes in premium amounts do not affect deductible amounts. B Either increase or decrease. C Decrease D Increase

C Decrease

Which of the following is NOT a cost-saving service in a medical plan? A Second surgical opinions B Risk sharing C Denial of coverage D Preventive care

C Denial of coverage

In individual health insurance coverage, the insurer must cover a newborn from the moment of birth, and if additional premium payment is required, allow how many days for payment? A Within 10 calendar days B Within 15 working days C Within 31 days of birth D Within a reasonable period of time

C Within 31 days of birth

To be eligible under HIPAA regulations, for how long should an individual converting to an individual health plan have been covered under the previous group plan? A 5 years B 12 months C 63 days D 18 months

D 18 months

Which of the following is the term for the specific dollar amount that must be paid by an HMO member for a service? A Deductible B Premium C Cost share D Copayment

D Copayment

A new employee who meets HIPAA eligibility requirements must be issued health coverage on what basis? A Noncancellable B Nondiscriminatory C Indemnity D Guaranteed

D Guaranteed

Which of the following health care plans would most likely provide the insured/subscriber with comprehensive health care coverage? A Group dental insurance plan B Medical-surgical expense plan C Basic medical expense plan D Health Maintenance Organization plan

D Health Maintenance Organization plan

Which is true regarding HMO coverage? A It is divided based on the average tax bracket of a family. B It is divided by state. C HMOs provide nationwide coverage. D It is divided into geographic territories.

D It is divided into geographic territories.

An insured's health claim internal appeal was denied. The insurer must do all of the following EXCEPT A Notify the insured about the decision in writing. B Complete the appeal in 60 days after service was received. C Notify the insured how to obtain an outside review. D Offer a payment plan.

D Offer a payment plan.

All of the following are considered to be basic benefits of an HMO plan EXCEPT A Preventive services. B Out-of-area coverage. C Diagnostic laboratory services. D Prescription drugs.

D Prescription drugs.

A man's physician submits claim information to his insurer before she actually performs a medical procedure on him. She is doing this to see if the procedure is covered under the patient's insurance plan and for how much. This is an example of A Concurrent review. B Claims-delayed treatment. C Suspended treatment. D Prospective review.

D Prospective review.

Which of the following is NOT provided by an HMO? A Services B Financing C Patient care D Reimbursement

D Reimbursement

A medical insurance plan in which the health care provider is paid a regular fixed amount for providing care to the insured and does not receive additional amounts of compensation dependent upon the procedure performed is called A Prepaid plan. B Indemnity plan. C Reimbursement plan. D Fee-for-service plan.

Prepaid plan.