TEST 2 Review (ch. 11-18)
it is available
Relationship between group health insurance plans and medicare.. Coverage is or is NOT available for workers over age of 65?
Employer and insurance company
A group health insurance policy is a contract between an
General Nursing care
A major medical expense plan typically includes coverage for hospital room and board. Which of the following is normally covered under the category "room and board"?
The Centers for Medicare and Medicaid services (CMS)
All parts of the medicare program are administered by wihch federal agency?
Flat Deductible
Amount of covered expenses payable by the insured before medical benefits are payable.
drugs dispensed through participating pharmacies
An HMO prescription drug plan is generally characterized by
Both the cause and resultant injury must be accidental
An accident and health insurance policy defines an injury as "bodily injury by accidental means" for an injury to be covered on this policy, what is required?
somewhat less
Christine is recieving benefits provided from her disability income insurance. As compared to her previous earnings, the disability benefits should be
$240 100+400=500. 500-200(deductible)= 300 300x80%=$240
Dan has a major medical expense policy with a $200 deductible and 80/20 coinsurance provision. he incurs covered medical expenses of $100 in November and $400 in January. Under the carryover provision, what will the insurer pay?
COBRA laws
For employees covered in multiple states under a group health plan, jurisdiction rules cannot alter
Exempt from income taxes
How are benefit payments from individually-owned medical expense policies treated for tax purposes?
not tax-deductible at all
How are the premiums for an individually-owned disability income policy treated for tax purposes?
Using certified nurse midwives
How do birthing centers reduce medical costs?
at least once per year from when benefits begin (bc of inflation)
If a disability income policy contains a cost-of-living adjustment rider, benefits must typically be increased
Disability income
Individuals covered with employer-paid group health plans will normally recieve tax-free benefits under all of these plans EXCEPT
Flat deductible
Major Medical policies are typically characterized by which of the following?
Custodial care
Major medical plans typically exclude coverage for which of the following benefits?
perform the substantial and material duties of his regular job
Mark is covered by a policy that uses the regular occupation definition of total disability. Using this definition, he will be considered disabled if unable to
Must have financial need
Medicaid will pay for nursing home expenses under what condition
120 days of skilled nursing facility care.
Part A Medicare includes coverage for all of the following services EXCEPT
40 quarters (10 years)
Social Security disability income requirements state that in order to become fully insured on a permanent basis, you must have worked in a covered occupation for
trust
States will permit the grouping of two or more small employers in the same industry for obtaining group health insurance at a favorable rate. this grouping of employers is known as a multiple employer
Steve will pay taxes on the disability benefit recieved from his employer, but will recieve any residual disability benefits tax-free
Steve has a group disability income policy where the premiums are paid by his employer. He elected to pay for additional residual disability coverage. which of the following statements is true?
excluded from coverage
Terry suffers an injury at his workplace which is coverd by workers compensation. Terry also has a medical expense insurance policy. Under medical expense insurance policies, losses that are covered by workers compensation are typically
Preferred Provider Organization (PPO)
The agreement in which hospitals and physician groups in a specific area contract with an insurance company to provide medical care at predetermined costs is
Her employer's group accident and health plan
Tonya has been diagnosed with kidney failure and has group accident and health insurance through her large employer. Which of these accident and health plans will be primary during the months following her diagnosis?
Protect against medical care costs and the loss of earnings power
The main role of accident and health and disability insurance is to
The sponsoring group provides an employer-employee relationship
Under which circumstance can an insurance company offer group health insurance?
Limit the amount of benefits an insured can receive from two disability policies with the same insurer
What action can an insurer take to discourage malingering and false disability claims?
Higher out-of-pocker expenses
What can be expected when a preferred provider organization (PPO) patient decides to use a non-PPO
A specific illness or event
What do limited accident and health policies normally cover?
Covers the approved cost of the rehabilitation necessary to help a disabled insured return to work
What does the rehabilitation benefit cover in a disability income policy?
the insured's education, training, and experience
What is taken into consideration when defining "Total disability" in a disability income insurance policy?
Shorten the benefit period
When issuing disability income coverage to a substandard risk, an insurance company may
Policy proceeds are typically received income tax-free.
Which of the following BEST describes disability buy-sell insurance policies?
Income level of group members
Which of the following does NOT help determine group health insurance premiums?
Military Families
Which of the following does TRI-CARE provide accident and health coverage to?
Treatment in a government facility
Which of the following does medical expense insurance NOT typically cover?
Post-termination extensions of medical benefits must apply equally to pregnancy
Which of the following guidelines does NOT apply under the pregnancy provision of the Civil RIghts Act?
Pays a death benefit as a result of natural causes
Which of the following is NOT a function of accident and health insurance?
Reduce fraudulent claims
Which of the following is NOT a reason the government provides insurance?
rehabilitation
Which of the following is NOT included as a hospice benefit under a major medical plan?
Hospitals can only initiate preferred provider plans
Which of the following is NOT true of a preferred provider plan?
Physical exams of group members
Which of these is NOT a factor that influences group health insurance underwriting?
Loss of sight in one eye
Which of these would NOT likely qualify as a presumptive disability?
Coverage excludes nonoccupational injuries
Which statement is true about a permanent disability under workers compensation coverage?
Disibility income
Which type of group plan is excluded from HIPAA rules
Marketing the plan
a MET third party administrator may NOT perform which of the following functions
The insured must be actively at work for a specified number of hours per week.
an insured, age 67, is covered under a disability income policy. What will the insurer normally require in order for the insured to continue coverage?
65
at what age do most people become eligible for Medicare?
What is COBRA?
requires most private employers to continue to make health benefits available to separated employees and their families for a time, generally 18 months after separation; the former employee must pay for the coverage
3
the major medical deductible carryover period normally applies to expenses incurred during the last _____ months of the plan year
Benefits are not taxable
what is the federal income tax liability of a death benefit paid from a health insurance policy to a named beneficiary?
50
what is the maximum number of employees an employer may have for qualified medical savings accounts?
suicide
which of the following incidents would NOT be covered by an accidental death and dismemberment policy?
Elimination Period
which of the following would permit an insurer to delay a covered disability policy claim?