Chapter 16 Study Guide
The federal- and state-sponsored health insurance program for the medically indigent is called....
MEDICAID
Under which of the following Medicare plans for primary care and specialists' services is the patient required to pay a monthly premium?
Part B
The physician who enters into a contract with an insurance company and agrees to certain rules and regulations is called a ______ provider.
Participating
The amount of money paid to keep an insurance policy in force is the...
Premium
Most of today's health insurance policies cover which of the following?
Preventive Care and Procedures deemed medically necessary.
Which type of referral is usually processed immediately?
STAT
Which of the following referrals can be approved online when it is submitted through the provider's Web portal to the utilization review department?
STAT referral
Organizations that fund their own insurance programs offer their employees....
Self-funded plans
Dependents of military personnel are covered by which of the following government-sponsored health insurance plans?
TRICARE
Health insurance designed for military dependents and retired military personnel is called..
TRICARE
The TRICARE option that is similar to a preferred provider network is ...
TRICARE EXTRA
A type of insurance that protects workers from loss of wages after an industrial accident that happened on the job is called...
Workers compensation.
Medigap policies cover which of the following?
a. Difference between major medical reimbursement and patient financial responsibilities
Which statement is NOT true about Medicaid.
d. Only patients over 65 qualify for Medicaid
If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay, how much will his insurance pay on his bill of $4,359?
$3,809
If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay and then pays 80% of the charges, how much will his policy pay on his bill of $4,359?
$3047.20
Which of the following is not a disadvantage of managed care?
A. Authorized services usually are covered.
The maximum amount of money third-party payers will pay for a specific procedure or service is called the...
Allowable Amount
Which of the following is not an advantage of managed care?
B. Access to specialized care and referrals is limited.
Which of the following HMO models hires physicians and pays them a salary rather than contracting the physicians to create a network?
B. Staff Model
The amount payable by an insurance company for a monetary loss to an individual insured by that company, under each coverage is called the....
Benefits.
Which of the following plans require healthcare providers to become participating providers?
Both A and B
Which of the following individuals would not normally be eligible for Medicare?
C. A 23 year old recipient of AFDC
Which of the following expenses would be paid by Medicare Part B?
C. Physicians Office Visits.
Veterans of the U.S. armed forces may be covered by....
CHAMPVA
________ is a form of government insurance for veterans of the U.S. armed forces.
CHAMPVA
A payment method in which providers are paid for each individual enrolled in a plan, regardless of whether the person sees the provider that month, is called a ______ plan.
Capitation plan
Which part of Medicare covers prescription drug services?
D.
The medical assistant should always verify which of the following prior to the patient's appointment?
D. All of the Above
Which of the following are not reviewed by a utilization review committee?
D. Fees for services provided.
The amount of money the policyholder pays per claim or per accident toward the total amount of an insured loss before the company will pay on the claim is known as the...
Deductible
Health insurance typically covers services and procedures considered medically necessary. Most insurance policies also cover "elective" procedures, such as certain cosmetic surgeries, that are not considered medically necessary.
False.
A policy that covers a number of people under a single master contract issued to the employer or to an association with which they are affiliated and that is not self-funded is usually called...
Group Policy
Which of the following MCOs typically has/have the lowest monthly premiums with lower patient financial responsibility?
HMO's
Which of the following managed care plans require preauthorization for medical services such as surgery?
HMO's and PPO's
Which of the following pays the hospital surgical room fee?
Hospital.
The insurance plan that 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, is known as
Indemnity (fee-for-service)
Health Insurance benefits are determined by...
Indemnity Schedules. Service Benefit Plans.Relative Value Studies
Which type of HMO model consists of physicians with separately owned practices who formally organize into a group but continue to practice in their own offices?
Independent Practice Association
Employee-sponsored group policies usually provide greater benefits at lower premiums because of the large pool of people from whom premiums are collected. However, these employee-sponsored group health insurance plans offer limited benefits, and healthcare access is limited to healthcare providers that are contracted with them.
The first statement is true; the second is false.
Entities that make payment on an obligation or debt but are not parties of the contract that created the debt are called...
Third-party payers.
A review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources is called a(n)
Utilization Review
