Chapter 13 - 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 insured's 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 do most people become eligible for Medicare?

65

Medicare can be described as

A federal health insurance program for individuals over the age of 65 or permanently disabled

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

An accident and health plan that typically covers ONLY the services of approved providers is called a(n)

An HMO plan

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. Which factor could possibly reduce these benefits?

Benefits he receives from workers compensation

Health Maintenance Organization (HMO) wellness programs may include each of the following EXCEPT

Diagnostic Testing Services

The benefit period of Medicare Part A begins on the first day the insured

Enters a hospital

The difference between a doctor's actual charges and the amount approved by Medicare is referred to as a(n)

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

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 a pre-paid service basis?

HMO

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

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 organizations (PPO) is

If service is obtained outside the PPO, benefits are reduced and costs increase

In a 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

After the initial enrollment period for Medicare Part B has expired, when may an individual purchase again?

January through March of each year

Inpatient psychiatric 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 perform 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

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

Military families

What is the eligibility requirement for Medicare Part B?

Must be eligible for Medicare Part A

Medicaid will pay for nursing home expenses under what condition?

Must have financial need

Specialty care is provided by which of the following health maintenance organization (HMO) providers?

Neurologist

Which of the following is NOT true of participants in multiple-employer trusts?

Participants must purchase all coverages the trust offers

A physician who accepts assignment on all Medicare claims is called a(n)

Participating Provider

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

Preferred Provider Organization (PPO)

After joining a health maintenance organization (HMO), a subscriber will typically select 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

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 of benefits

Medicare Part A covers which type of care?

Skilled nursing facility care

If an individual would like to enroll in Medicare or seek public information about Medicare, which federal agency handles this?

Social Security Administration

An individual may receive Medicare Part A Hospital benefits, regardless of age, as long as the person has received which of the following benefits for at least 24 months?

Social Security Disability

Individuals who participate in an HMO plan are called

Subscribers

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

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

An HMO prescription drug plan is generally characterized by

drugs dispensed through participating pharmacies