Health Insurance Providers
How does one become eligible for Part D: Prescription Drug coverage? Must meet certain underwriting guidelines Must have a valid prescription Must have Medicare coverage Must have Medicaid coverage
Must have Medicare coverage
Which payment method for a health claim settlement is typically made directly to the provider of the services? Settlement Fee-for-service Premium payment Prepaid
Prepaid
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
Provides a greater choice of providers
What is Medicare Part B also known as? Medicare supplement Supplementary medical insurance Comprehensive insurance Medicaid
Supplementary medical insurance
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
When becoming eligible for Medicare
Medicare provides coverage for each of the following EXCEPT hospital room and board doctor and surgeon services prescription drugs custodial care
custodial care
Medicare Part B covers long-term care hospital room and board doctor's charges prescription drugs
doctor's charges
Medicare Part A does not pay for medical benefits provided for treatment in a skilled nursing facility beyond 30 days 60 days 100 days 120 days
100 days
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
100% of the billed amount.
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
65
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 Social Security A 55-year old suffering from kidney failure A 65-year old retiree
A 70-year old NOT eligible for social security
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
Accept payment based upon a defined Medicare schedule as payment in full
Maria is a Preferred Provider Organization (PPO) subscriber and received care from an out-of-network provider. Which of the following is the likely result? Care is covered Care is not covered Care is only covered in a government facility Care is only covered if primary care physician gives a referral
Care is covered
Which of these is NOT a qualifying event for Medicare? On Social Security disability for over 2 years Kidney failure Age 65 or older Falling below the federal poverty level
Falling below the federal poverty level
A health care provider claim may be settled using which of the following payment methods? Litigation Unfair claim settlement Fee-for-service Prepaid expense
Fee-for-service
Which of these will typically authorize treatment from a specialist? Administrator Policyowner Insurance company Gatekeeper
Gatekeeper
How is Medicare Part B funded? Employer taxes Payroll taxes User premiums General tax revenue and user premiums
General tax revenue and user premiums
Which of the following is NOT taken into consideration when determining eligibility for Medicare benefits? Chronic kidney disease Income Age Social Security disability
Income
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
Group HMO
The open enrollment period for Medicare Part B is January 1 through March 31 January 1 through April 30 January 1 through May 31 January 1 through June 30
Jan 1- March 31
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
John
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
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
MEWA
Which of the following is Medicare Part B also known as? Hospital insurance Medical insurance Long-term care insurance Medigap
Medical insurance
The role of the federal government was expanded when Medicaid was established by allowing the state to form a large PPO on a statewide level purchase health insurance from the federal government receive matching funds to expand public assistance programs defer all costs to the federal government for public assistance programs
Receive matching funds to expand public assistance programs
When a preferred provider organization (PPO) insured goes out-of-network, which of the following actions occur? The insured will pay a reduced amount The benefits are taxable The insured has lower out-of-pocket expenses The insurer will pay a reduced amount
The insurer will pay a reduced amount.
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? Will be the primary insurer and pay for 100% of covered expenses Will be the secondary insurer and pay for claims not fully covered by the group plan Will not pay for any of the covered expenses Will be the primary insurer and the group plan will be secondary
Will be secondary insurer, and pay for claims not fully covered by the group plan
Medicare Part A covers outpatient services doctor's fees inpatient hospital stay prescription drugs
inpatient hospital stay
An accident and health policy that provides reimbursement benefits makes them payable to the provider facility providing service insured insured's spouse
insured
Paul is an employee who caught a disease unique to the trade in which he was exposed to. Paul has a(n) genetic predisposition worksite malady contagious disease occupational disease
occupational disease
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
poor people
Medicaid is intended for people with kidney failure people aged 65 and older unemployed people poverty stricken people
poverty-stricken people
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
prepaid
An individual covered under a Blue Cross Blue Shield plan is called a(n) participant subscriber policyowner insured
subscriber
Funding for Medicare Part B is partially provided by Municipal bonds State bonds private insurers user premiums
user premiums
What type of injury would NOT be covered under a health insurance policy? Accidental Work-related Sports-related Recreational
work-related