CH. 2: Health Insurance Providers

Will be the secondary insurer and pay for claims not fully covered by the group plan

A 70-year old insured individual has suffered from kidney failure for the past 24 months. She is covered by her spouse's large-group employer plan. How will Medicare be utilized in this situation? a) Will be primary insurer and pay for 100% of covered expenses b) Will be the secondary insurer and pay for claims not fully covered by the group plan c) Will not pay for any of the covered expenses d) Will be the primary insurer and the group plan will be secondary

100% of the billed amount

A closed network plan offers a a primary physician copay of $25. If a subscriber chooses a primary care physician outside of the network, the subscriber will likely pay $0 $25 100% of the billed amount 100% of the allowed amount

Fee-for-service

A health care provider claim may be settled using which of the following payment methods? Litigation Unfair claim settlement Fee-for-service Prepaid expense

Accept payment based upon a defined Medicare schedule as payment in full

A medical provider that accepts Medicare Assignment must Accept payment based upon a defined Medicare schedule and bill the insured for any difference Accept payment based upon a defined Medicare schedule and negotiate any excess fees Accept payment based upon a defined Medicare schedule and bill no more than 15% of the excess charges Accept payment based upon a defined Medicare schedule as payment in full

Group HMO

An HMO that involves a partnership of physicians and other providers who practice out of a central facility is called a(n) Group HMO Federal HMO Central HMO Managed HMO

Insured

An accident and health policy that provides reimbursement benefits makes them payable to the Provider Facility providing service Insured Insured's spouse

When becoming eligible for Medicare

An individual can enroll in a Part C Medicare Advantage Plan at what time? When becoming eligible for Medicaid At age of retirement Age 59 1/2 When becoming eligible for Medicare

Subscriber

An individual covered under a Blue Cross Blue Shield plan is called a

Age 65

At what age will a person normally enroll with an insurance carrier under a Part C Medicare Advantage Plan? Age 59 1/2 Age 60 Age 62 Age 65

John

Donna and Mary were racing bicycles in a store parking lot while being cheered on by fellow employees. Mary ran into John, another employee, who happened to be taking out the garbage. Both Mary and John are injured. Who would most likely be covered under Workers' Compensation? John Mary John and Mary Neither of them

Must have Medicare coverage

How does one become eligible for Part D: Prescription Drug coverage? Must meet certain underwriting guidelines Must have a valid presciption Must have Medicare coverage Must have Medicaid coverage

Poor people

Medicaid is a government-funded program designed to provide health care to All individuals over the age of 65 All individuals who carry Medicare supplemental insurance Anyone who does not have a proper caregiver Poor people

Inpatient hospital stay

Medicare Part A covers Outpatient services Doctor's fees Inpatient hospital stay Prescription drugs

Doctor's charges

Medicare Part B covers which of the following? Long-term care Hospital room and board Doctor's charges Prescription drugs

Custodial care

Medicare provides coverage for each of the following EXCEPT Hospital room and board Doctor and surgeon services Prescription drugs Custodial care

A 70 - year old NOT eligible for SS

Part A Hospital expense coverage provided under Medicare is automatically made available to each of the following EXCEPT A 50 - year old individual who has qualified for SSDI in the last 24 months A 70 - year old NOT eligible for SS A 55 - year old suffering from kidney failure A 65- year old retiree

MEWA

Small employers who are sponsored by an insurer to provide group benefits to its employees are called Fraternal Benefit Society Surplus lines brokers Lloyd of London MEWA

Prepaid

The Federal Employees Benefit Program consists of two types of health plans for federal civilian employees. The two plans are fee-for-service and Prepaid Ambulatory Facility Blanket

Jan 1 - March 31

The open enrollment period for Medicare Part B is Jan 1 - March 31 Jan 1 - April 30 Jan 1 - May 31 Jan 1 - June 30

Receive matching funds to expand public assistance programs

The role of the federal government was expanded when Medicaid was established by allowing the state to a) Form a large PPO on a statewide level b) Purchase health insurance from the federal government c) Receive matching funds to expand public assistance programs d) Defer all costs to the federal government for public assistance programs

Supplementary Medical Insurance

What is Medicare Part B also known as? Medicare Supplement Supplementary Medical Insurance Comprehensive insurance Medicaid

Work-related

What type of injury would NOT be covered under a health insurance policy? Accidental Work-related Sports-related Recreational

Provides a greater choice of providers

When comparing an HMO to a PPO, the PPO Always requires service in a network Provides a greater choice of providers Always requires a referral to specialists Is a prepaid medical service plan

Multiple Employer Welfare Arrangement (MEWA)

Which of the following is a legal entity created for the sole purpose of providing affordable group health coverage to its participants? Multiple Employer Welfare Arrangement (MEWA) Multiple Trust Arrangement (MTA) Multiple Purchasing Groups (MPG) Fraternal Benefit Society