ch.23

the health insurance model that offers the MOST flexibility for patients is

traditional health insurance

TRICARE is a form of government insurance for veterans of the U.Ss armed forces T or F

false

in some managed care plans referrals to a specialist must be approved by the

gatekeeper

a policy that covers a number of people under a single contract issued to the employer

group policy

the health insurance mode that offers the LEAST flexibility for patients is

health maintenance organization

which type of HMO model consists of a provider group that contracts with one or more HMOs, but can also patients outside of the HMO

independent practice association

the federal and state funded health insurance program for the medically indigent is called

medicaid

services that are needed to improve the patients current health are considered

medically necessary

the physician who enters into a contract with an insurance company and agrees to certain rules and regulations is called a __________ provider

participating

which of the following expenses would be paid by Medicare Part B

physicians office visits

a written agreement between two parties, where one party agrees to pay another party if certain specified circumstances occur is a

policy

a process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services is

preauthorization

the amount of money paid to keep an insurance policy in force is the

premium

An order from a primary care provider for the patient to see a specialist is a(n):

referral

the allowed amount for Medicare charges is determined using

resource- based relative value scale

organizations that fund their own insurance programs offer their employees

self-funded plans

veterans of the U.S. armed forces may be covered by

CHAMPVA

a formal request for payment form an insurance company for services provided is

claim

a certain percentage of the allowed amount that the policyholder is responsible for is

co-insurance

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. T or F

false

someone who is poor, needy, or impoverished is considered

indigent

which of the following plans require healthcare providers to become participating providers

Both A&B

which part of Medicare covers prescription drug services

D

individual health insurance plans cover only one person T or F

False

a set dollar amount that the policyholder must pay for each office visit is

co-pay

the amount of money the policyholder pays per claim before the insurance company will pay on the claim is known as the

deductible

A document sent by the insurance company to the provider and the patient explaining the allowed charge, the amount reimbursed for services, and the patient's financial responsibilities is

explanation of benefits

Medigap policies cover which of the following

all of the above

RBRVS consists of three parts, including which of the following?

all of the above

the Affordable Care Act includes which of the following categories of essential health benefits

all of the above

the medical assistant should always verify which of the following prior to the patients appointment

all of the above

a designated person who receives funds from an insurance policy is

beneficiary

a provider can choose whether to accept Medicaid patients T or F

True

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

there are no government managed care plans T or F

false

a list of the fixed fees for services is a

fee schedule

which of the following are NOT reviewed by a utilization review committee

fees for services provided

service provided to stop certain conditions from occurring or to lead to an early diagnosis are considered

preventive

an approved list of physicians, hospitals, and other providers is an

provider network

an organization that processes claims and provides administrative services for another organization is

third-party administrative

which of the following individuals would NOT normally be eligible for Medicare

a 23 yr old recipient of AFDC

which of the following services must be covered by Medicaid in each state

All of the above

which of the following MCOs typically has/have the lowest monthly premiums with lower patient financial responsibility

HMOs

which part of the Medicare covers inpatient hospital charges

Part A

under which of the following Medicare plans for primary care and specialists services is the patient required to pay a monthly premium

Part B

health insurance designed for military dependents and retired military personnel is called

TRICARE

Employer 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.

which of the following managed care plans require preauthorization for medical services such as surgery

all of the above

a review of individual cases by a committee to make sure that services are medically necessary is called a(n)

utilization review

a type of insurance that protects workers from loss of wages after an industrial accident that happens on the job is called

workers compensation