Chapter 5: health insurance providers
Medicare will cover a maximum of how many days per benefit period in a skilled nursing facility?
100 days
what is the maximum social security disability benefit amount an insured can receive?
100% of the insurds primary insurance amount (PIA)
what is the maximum social security disability benefit amount an insured can receive?
100% of the insureds primary insurance amount (pia)
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
Part A Medicare includes coverage for all of the following services EXCEPT
120 days of skilled nursing facility care
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
40 quarters
at what age should most people become eligible for medicare?
65
what age do most people become eligible for medicare?
65
medicare part A does not provide coverage for
First 3 pints of blood
the coinsurance for skilled nursing facility services covered by medicare after the 100% medicare coverage ends is
Flat dollar amount per day
an organization that requires healthcare services to be provided by a network of physicians and hospitals is known as
HMO
an organization that requires healthcare services to be provided by a network of physicians and hospitals is known as a(n)
HMO
which of the following health plans pay benefits on pre paid service basis?
HMO - health maintenance organizations
an accident and health plan that typically covers only the services of approved providers is called an
HMO Plan
an accident and health plan that typically covers only the services of approved providers is called an
HMO plan
after the initial enrollment period for medicare part b has expired when may an individual purchase again?
January through march of each year
a MET third party administrator may not preform which of the following functions?
Marketing the plan
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
PPO Preferred provider organization
medicare part A covers which type of care?
Skilled nursing facility care
Medicare can be described as
a federal health insurance program for individuals over the age of 65 or permanently disabled
what is a major difference between private commercial insurers and hmo?
an HMO combines medical care and funding in one organization
rick is a disabled worker receiving social security benefits. what benefits are his wife and dependent children eligible for ?
an income benefit which is a percentage of his primary insurance amount
Tim had an on-the-job accident and collects benefits from his individual disability income policy. What factor could possibly reduce these benefits?
benefits he receives from workers comp
which statement is true about a permanent disability under workers compensation coverage?
covers excludes on occupational injuries
health maintenance organization (hmo) wellness programs may include each of the following EXCEPT
diagnostic testing services
An HMO prescription drug plan is generally characterized by
drugs dispensed through participating pharmacies
the benefit period of medicare part A begins on the first day
enters a hospital
the difference between a doctors actual charges and the amount approved by medicare is referred to as a(n)
excess charge
the difference between a doctors actual charges and the amount approved by medicare is referred to as an
excess charge
Terry suffers an injury at his workplace which is covered 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
excluded from coverage
federally qualified HMO's must offer
family planning services
where does the primary funding for medicare part A come from?
federal payroll and self employment taxes
Medicare part A does not provide coverage for
first 3 pints of blood
Emily is disabled. In order to become eligible for Social Security disability income benefits, she must be
fully insured according to social security
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?
her employers group accident and health plan
what can be expected when a preferred provider organization (ppo) patient decides to use a non PPO
higher out of pocket expenses
which of the following is not true of a preferred provider plan?
hospitals can only initiate preferred provider plans
a characteristic of preferred provider organization (PPO) is
if service is obtained outside of the PPO benefits are reduced and the costs increase
in staff model HMO enrollees normally have which of the following pharmacy options available to them?
in-house pharmacy
medicare part A typically covers
inpatient drugs
which of these procedures is not designed for ambulatory care centers?
inpatient surgery
Ken is age 65 and has 2 years until he receives Social Security retirement income benefits. At his current age, which is true about Medicare Part A Hospital Insurance coverage?
it is available through application to social security
inpaitent psychiatric care is covered under part A medicare for 190 days per
lifetime
inpatient psycgiatric care is covered under Part A Medicare insurance for 190 days per
lifetime
inpatient psychiatric care is covered under Part A Medicare for 190 days per
lifetime
employees generally receive workers compensation benefits for
lost wages and medical expenses due to occupational accidents
a MET third party administrator may not preform which of the following functions?
marketing the plan
skilled nursing facility expenses are sometimes covered by ___-- but only if the insured was hospitalized prior to entering the facility
medicare
skilled nursing facility expenses are sometimes covered by ________ but only if the insured was hospitalized prior to entering the facility
medicare
which of the following does TRI-Care provide accident and health coverage to?
military families
what eligibility requirement is medicare part B?
must be eligible for part A
Medicaid will pay for nursing home expenses under what condition?
must have a financial need
specialty care is provided by which of the following health maintenance organization (HMO) providers?
neurologist
Which of the following is not true f participants in multiple-employer trusts?
participants must purchase all coverage the trusts offers
a physician who accepts assignment n all medicare claims is called an
participating provider
Karen is a health maintenance organization HMO subscriber. who provides all of her preventative and routine care?
primary care physician
after joining a health maintenance organization (hmo) a subscriber will typically select a
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? A. Receive permission from the primary physician to begin treatment B. Call the HMO to verify coverage C. Proceed to the nearest emergency room D. Contact the HMO for a listing of approved providers
proceed to the nearest emergency room
which of the following is not a reason the government provides insurance?
reduce fraudulent claims
Third-party administration has become fairly common in accident and health insurance due to the growth of
self- funding benefits
if an individual would like to enroll in medicare or seek public information about medicare which federal agency handles this?
social securities administration
an individual may receive Medicare part A hospital benefits regardless of age as long as the person has received which of the following for at least 24 months?
social security disability
an individual may receive medicare Part A hospital benefits regardless of age as long as the persons have received which of the following benefits for at least 24 months?
social security disability
individuals who participate in an HMO plan are called
subscribers
why might it be beneficial for an employee to purchase private disability income insurance for workplace injuries when he/she is already covered by workers compensation?
the benefits arising from a workers compensation claim could be inadequate to replace the loss if income
why might it be beneficial for an employee to purchase private disability income insurance for workplace injuries when he/she is already covered by workers compensation?
the benefits arising from a workers compensation claim could be inadequate to replace the loss of income
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
which of the following is not a reason the government provides insurance?
to reduce fraudulent claims
the grouping of two or more small employers in order to obtain group health insurance at a favorable rate is called multiple employer
trust
