Chapter H2: Health Insurance Providers

The coinsurance for skilled nursing facility services covered by Medicare after the 100% Medicare coverage ends is

A flat dollar amount per day

What is a major difference between private commercial insurers and HMO's?

An HMO combines medical care delivery and funding in one organization

medicare part a and part b do not pay for

Dental Care

Emily is disabled. In order to become eligible for Social Security disability income benefits, she must be

Fully insured, according to Social Security

The health insurance program which is administered by each state and funded by both the federal and state governments is called: 1) Long-term care 2) Medicaid 3) Medicare Supplemental Program 4) Medicare

Medicaid Medicaid is funded by both the federal and state governments and administered by individual states.

The percentage of an individual's Primary Insurance Amount (PIA) determines the benefits paid in which of the following programs?

Social Security Disability Income

Individuals who participate in an HMO plan are called

Subscribers

Which of the following statements is true about most Blue Cross/Blue Shield organizations?

They are nonprofit organizations

Medicare is intended for all of the following groups EXCEPT

Those enrolled as a full-time student

Which of the following types of organizations are prepaid group health plans, where members pay in advance for the services of participating physicians and hospitals that have agreements?

A Health Maintenance Organization (HMO) is a prepaid group health plan, where members pay in advance for the services of participating physicians and hospitals that have agreements.

What is Medicare? 1) A disability program 2) A hospital and medical expense insurance program 3) Offers assistance in making health insurance premiums 4) Part D provides payment for surgeon expenses

A hospital and medical expense insurance program Medicare is a hospital and medical expense insurance program

Individuals seeking Social Security disability income benefits must have a disability that will eventually lead to death, or be expected to last at least

12 months

All parts of the Medicare program (except for public information and enrollment) are administered by which federal agency?

The Centers for Medicare and Medicaid Services

Why might it be beneficial for an employee to purchase private disability income insurance for workplace injuries when he/she is already covered by worker's compensation?

The benefits arising from a worker's compensation claim could be inadequate to replace the loss of income

Under what system do a group of doctors and hospitals in a designated area contract with an insurer to provide services at a prearranged cost to the insured?

PPO

The situation in which a group of physicians are salaried employees and conduct business in an HMO facility is called a(n): 1) closed panel 2) open panel 3) co-op panel 4) capitation panel

closed panel A closed panel is when an HMO is represented by a group of physicians who are salaried employees and work out of the HMO's facility.

Which of the following does TRI-CARE provide accident and health coverage to?

Military families

Medicaid will pay for nursing home expenses under what condition?

Must have financial need

what does medicare parts a and b cover

Part A covers hospitalization; Part B covers doctor's services

Third-party administration has become fairly common in accident and health insurance due to the growth of

Self-funding of benefits

Which type of provider is known for stressing preventative medical care?

Health Maintenance Organizations (HMO's)

The individual who provides general medical care for a patient as well as the referral for specialized care is known as a

Primary Care Physician.

Karen is a health maintenance organization (HMO) subscriber. Who provides all of her preventative and routine care?

Primary care physician

Which of the following does NOT fall under "hospital care" in a typical health maintenance organization (HMO) plan?

Private duty nursing

Alan is an enrollee of a health maintenance organization (HMO) which uses a gatekeeper system. If there ever comes a time when he needs emergency health services, what should he do?

Proceed to the nearest emergency room

What is the maximum Social Security Disability benefit amount an insured can receive? 1) 50% of the insured's Primary Insurance Amount (PIA) 2) 75% of the insured's Primary Insurance Amount (PIA) 3) 100% of the insured's Primary Insurance Amount (PIA) 4) 100% of the insured's Primary Insurance Amount (PIA) minus any monies received from a retirement plan

100% of the insured's Primary Insurance Amount (PIA) The MAXIMUM Social Security Disability benefit an insured may receive is equal to 100% of the insured's Primary Insurance Amount (PIA)

Tim had an on-the-job accident and collects benefits from his individual disability income policy. Which factor could possibly reduce these benefits?

Benefits he receives from workers compensation

Which of the following organizations reimburses its insureds for covered medical expenses? 1) Administrative-services-only plan 2) Commercial insurer 3) Preferred provider organization 4) Health maintenance organization

Commercial insurer Commercial health insurance companies use the reimbursement approach, which allows policyowners to seek medical treatment then submit the charges to the insurer for reimbursement.

Which of the following organizations would make reimbursement payments directly to the insured individual for covered medical expenditures? 1) Administrative-services-only plan 2) Commercial insurer 3) Preferred provider organization 4) Health maintenance organization

Commercial insurer Commercial health insurance companies use the reimbursement approach, which allows policyowners to seek medical treatment then submit the charges to the insurer for reimbursement.

Which of the following does Social Security NOT provide benefits for? 1) Survivorship 2) Dismemberment 3) Disability 4) Retirement

Dismemberment Social Security provides for all of these types of benefits EXCEPT dismemberment

Which of these is considered a true statement regarding Medicaid?

Funded by both state and federal governments

A medical care provider which typically delivers health services at its own local medical facility is known as a

Health Maintenance Organization

J is a subscriber to a plan which contracts with doctors and hospitals to provide medical benefits at a predetermined price. What type of plan does J belong to? 1) Multiple Employer Welfare Arrangement 2) Multiple Employer Trust 3) Health Maintenance Organization 4) Co-op Arrangement

Health Maintenance Organization A health Maintenance Organization (HMO) contracts with doctors and hospitals to provide medical benefits to subscribers at a predetermined price.

Tonya has been diagnosed with kidney failure and is covered by group accident and health insurance through her large employer. Which of these accident and health plans will be primary during the months immediately following her diagnosis?

Her employer's group accident and health plan

A 66 year-old is covered under a group health plan while employed with a business that has 40 employees. If she injures herself while walking in the park, what coverage would be considered primary? 1) Medicaid 2) Long-term care 3) Medicare 4) Her group health plan

Her group health plan If the employer has more than 20 employees, the group health plan generally pays first.

Which of the following actions is required by an insured who leaves the primary area of medical coverage and seeks medical care? 1) Obtain prior approval from the NAIC for the medical service 2) Obtain prior approval from the insurer for the medical service 3) Take a physical examination prior to leaving the primary area 4) Sign a liability waiver from the insurer prior to receiving medical care

Obtain prior approval from the insurer for the medical service If an insured leaves the primary area of medical coverage and seeks medical care, the insured must first contact the insurer to obtain prior approval for the medical services.

Which of these statements is INCORRECT regarding a Preferred Provider Organization (PPO)?

PPO's are NOT a type of managed care systems

Which of the following BEST describes how a Preferred Provider Organization (PPO) is less restrictive than a Health Maintenance Organization (HMO)?

PPO's normally provide a wider choice of physicians and hospitals.

The grouping of two or more small employers in order to obtain group health insurance at a favorable rate is called a multiple employer

Trust Multiple Employer Trust (MET)

Medicaid was designed to assist individuals who are: 1) Federal employees 2) disabled 3) in poor health 4) below a specific income limit

below a specific income level Medicaid was enacted to provide medical assistance to those whose income is below a specific limit.