Health 1 (Chapters 15, 16, & 17)
An insured has a basic hospital expense policy with a $10,000 limit for benefits, coordinated with a major medical policy with a $500 corridor deductible and 80/20 coinsurance provision. If she incurs a loss of $20,000, how much will the insurer pay? $16,000 $15,600 $8,000 $17,600
$17,600
Rose Bud receives a hospital bill for $9,500 after being released from the hospital. Her Major Medical policy has a $500 deductible and an 80% - 20% continuous coinsurance feature. Of the total expense, how much will Rose have to pay? $1,800 $500 $2,300 $1,900
$2,300
Stagmite purchases a major medical policy with a $100 annual deductible, 80/20 co-insurance and a stop loss of $5000. If Stagmite were to incur covered expenses of $10,100, how much would Stag be out of pocket? $5000 $5100 $2000 $2100
$2100
Social Security was started in what year? 1925 1930 1935 1945
1935
Which of the following is the most common type of co-insurance in a major medical policy? 5 - 10% 10 - 15% 20 - 25% 25 - 30%
20 - 25%
How long is the waiting period before a person may file a claim for Social Security Disability benefits? 12 Months 5 Months 90 Days 6 Months
5 Months
The term FIRST DOLLAR often is used to describe benefits payable by which type of policy? A Hospital Indemnity policy A Disability Income policy A Business Overhead Expense policy A Major Medical policy
A Hospital Indemnity policy
Grouping small businesses together to obtain group insurance as one large group is characteristic of which of the following? A Health Maintenance Organization (HMO) A Franchise Health plan A Multiple Employer Trust (MET) A Fictitious group
A Multiple Employer Trust (MET)
A Hospital Expense policy that pays a FLAT AMOUNT per day for hospital room and board pays benefits on what basis? Billing Reimbursement Automatic A fixed-rate plan
A fixed-rate plan
All of the following may administer self-insured plans except: Third Party Administrators - TPAs Administrative Services Only - ASOs Actuaries Insurance Companies
Actuaries
Which of the following companies can sell health insurance? I. Mono-Line II. Home Service/Industrial III. Property/Casualty IV. Multi-Lines Company I II & III III & IV All the above
All the above
A Comprehensive Medical Expense policy combines the benefits of what two types of plans? Hospital Expense and Surgical Expense Basic Medical and Major Medical Major Medical and Disability A.D.& D. and Major Medical
Basic Medical and Major Medical
Which is not true concerning a Hospital Fixed-Rate plan? Claim costs are not affected by rising health care costs High benefits for relatively low premiums Simple underwriting and administration Benefits are paid directly to the hospital
Benefits are paid directly to the hospital
All of the following statements concerning Social Security disability benefits are true except: The impairment must be expected to last at least 12 months. The waiting period is 5 months. The waiting period may be waived in certain circumstances. Benefits are retroactive to the time of disability.
Benefits are retroactive to the time of disability.
Which of the following statements regarding workers' compensation plans is correct? Benefit amounts are mandated by the federal government A worker will qualify for benefits only if his disability or illness was a result of employer negligence Benefits may be financed by private insurers, state funds or self-insurance If a worker is killed in an industrial accident, his family is not entitled to a specified benefit amount to pay for burial expenses
Benefits may be financed by private insurers, state funds or self-insurance
What term describes the concept that the insurer and the insured share in the cost of medical expenses, with the insurer bearing the greater share? Deductible Stop-loss limit Coinsurance Benefit restoration
Coinsurance
An applicant for insurance may pay the initial premium and receive a document from the agent indicating that if the policy is issued as requested coverage begins on the date of the documents. What is this document called? Executing agreements Conditional receipt Warranty Notice of inspection
Conditional receipt
Another term used for Home Service insurers is: Franchise insurers Wholesale insurers Debit insurers Door to door insurers
Debit insurers
Basic Medical expense policies do not contain which feature? Deductibles Room & Board benefits Physician office visits Miscellaneous benefits
Deductibles
Which of the following is usually not considered health insurance? Dental Insurance Medical Expense Disability Insurance Acc. Death & Dismemberment
Dental Insurance
When benefits are paid to a policyowner covered under a Hospital Expense policy, the policy is considered to be which of the following? Service Limited Fixed-Rate plan Special Risk
Fixed-Rate plan
Which of the following about Health Reimbursement Accounts HRA's is/are correct? HRA's are established by the employer HRA's are established by the employee HRA's are established with after tax dollars HRA's are the least common of High Deductible Health Plans
HRA's are established by the employer
The type of health care provider that provides both the health care services and the health care coverage is a: Preferred Provider Organization Health Maintenance Organization Blue Cross/Blue Shield organization Traditional health insurance company
Health Maintenance Organization
Which of the following plans used with High Deductible Health Plans is employee owned? Health Savings Accounts (HSAs) Flexible Spending Accounts (FSAs) Health Reimbursement Accounts (HRAs)
Health Savings Accounts (HSAs)
Which type of coverage is least affected by an increase in medical costs? Basic Medical Expense Hospital Indemnity Comprehensive Medical Major Medical
Hospital Indemnity
Which of the following non-insurance entities are involved with self-insured plans? I. Third Party Administrator II. Administrative Services Organization III. Actuaries IV. Health Maintenance Organization I & IV III & IV I & II II & III
I & II
A certain major medical policy states a maximum number of days for which convalescent care will be paid as well as a maximum number of X-rays that will be paid for under any one claim. These are examples of: First dollar coverage Inside limits Carryover provisions Stop-loss limits
Inside limits
Which of the following may administer a self-funded HMO? Insurance company Actuary PEO TPA
Insurance company
Which of the following is true about coinsurance? Coinsurance applies to the deductible as well as to claim payments. Premiums are higher for a policy that contains a coinsurance provision than for one that does not. It helps control overutilization of benefits. Insurance companies can change the coinsurance ratio after the policy has been issued.
It helps control overutilization of benefits.
Which of the following statements is usually true about a Medical Expense policy? It is available on a group basis only. It covers accidental injuries only. It pays benefits on a cost-incurred basis only. It covers hospital expenses only.
It pays benefits on a cost-incurred basis only.
Which of the following most accurately describes the Health Maintenance Act of 1973? It requires all employers to offer enrollment into an HMO It requires all employers with 25 or more employees to offer enrollment into an HMO It requires all employers with 25 or more employees to offer enrollment into an HMO if they provide health care benefits to their workers It requires all employers with 25 or more employees to offer enrollment into an HMO as a minimum health care benefit offering
It requires all employers with 25 or more employees to offer enrollment into an HMO if they provide health care benefits to their workers
Which of the following is not considered a "service provider"? Lloyds of London Health Maintenance Organizations Preferred Provider Organizations
Lloyds of London
Basic Medical expense policies do not generally provide coverage for: Emergency room visits Lost income Surgical expenses Skilled nursing facility expenses
Lost income
Which is not a service provider? PPO MIB EPO HMO
MIB
Which medical expense plan is best suited for higher risks and greater loss? Major Medical Comprehensive Medical First-Dollar Dread Disease
Major Medical
If one becomes totally disabled, Social Security Disability benefits: May begin after 30 days May begin after 60 days May begin after three months May begin after six months
May begin after six months
All of the following are true about health insurance dividends except: Mutual (participating) insurers generally issue dividends Mutual (participating) insurers generally issue experience-rated plans Stock insurers generally issue experience-rated plans The two major factors that influence these are expenses and claims costs of the insurer
Mutual (participating) insurers generally issue experience-rated plans
All the following benefits from a major medical policy could be expected to be paid except: Dentists Optometrists Chiropractors Naturopaths
Naturopaths
Health insurance policies generally do issue dividends in which of the following circumstances? Health insurance policies never issue dividends Only individual health insurance policies issue dividends Only group health insurance policies issue dividends Both individual and group health insurance policies issue dividends
Only group health insurance policies issue dividends
Which of the following are NOT eligible for Medicare coverage? People age 65 and older eligible for Social Security People age 65 and older not eligible for Social Security, but willing to pay a monthly premium People of any age who have been entitled to S.S. Disability benefits People with any life threatening condition
People with any life threatening condition
Which of the following are NOT eligible for Medicare coverage? People age 65 and older who are eligible for Social Security People age 65 and older not eligible for Social Security, but willing to pay a monthly premium People of any age who have been entitled to S.S. Disability benefits People with any life threatening condition
People with any life threatening condition
When medical expense policies do not state specific dollar benefit amounts, but instead base payment upon the charges for the services in the same geographical area, benefits are designated as which of the following? Reasonable and Customary Approach Stated charges Percentage of stated charges Designated charges
Reasonable and Customary Approach
In a Basic Surgical policy, which of the following pays per point? Relative Value Surgical Schedule Reasonable and Customary Surgical Point
Relative Value
An agent completes an application for accident and health insurance at the home of a proposed insured, collects the initial premium, and returns to her office. Before transmitting the application and premium to her home office, she finds an error. She should do which of the following? She should correct the error and have the insured initial it when the policy is delivered. She should complete and sign the agent's report. She should send a copy of the application to the Medical Information Bureau (MIB). She should go back to the insured and have him/her initial the change on the application.
She should go back to the insured and have him/her initial the change on the application.
Health insurance may be written by all the following types of companies except: Life Casualty Surety Home Service
Surety
A Health Savings Account does not allow: Tax deductible contributions Tax free growth Tax free withdrawals Tax free non-qualified withdrawals
Tax free non-qualified withdrawals
Which of the following statements is true regarding Multiple Employer Trusts ? Multiple Employer Trusts require employers to have an employment-related common bond. The Multiple Employer Trust, not the employer, is the contract holder. Multiple Employer Welfare Arrangements are designed for those below a certain income level. An employer must subscribe to all the coverages of the Multiple Employer Trust.
The Multiple Employer Trust, not the employer, is the contract holder.
All of the following statements about noncancellable policies are true except: A noncancellable policy is also called a noncancellable and guaranteed renewable policy. The only right to cancel the noncancellable policy is for nonpayment of premiums. The insurer may increase the premium rate after the policy is in effect provided it does so by classes of insureds. The insurer may regain the right to cancel or not to renew when the insured reaches an age specified in the policy.
The insurer may increase the premium rate after the policy is in effect provided it does so by classes of insureds.
With regard to group insurance, who has the responsibility to apply for coverage, provide information about the group, maintain the policy, and pay premiums? The agent who wrote the group coverage The insurer that provides the group coverage The individuals that make up the group The master policy owner
The master policy owner
Which of the following statements about deductible provisions in medical insurance policies is NOT correct? They help to eliminate small claims They provide that initial expenses up to a specified amount are to be paid by the insured They are most common in basic medical expense policies They help to hold down premium rates
They are most common in basic medical expense policies
Which statement concerning commercial companies is not true? They function on the reimbursement approach. They have a right of assignment built into many policies. They are not debit companies. May be monoline companies.
They are not debit companies.
Which of the following is not correct concerning Health Maintenance Organizations? Members may be part of a group, individual, or family plan. They may be self-funded. They finance health care on a pre-payment basis. They mandate enrollment for groups of 25 or more.
They mandate enrollment for groups of 25 or more.
Which of the following statements is true about Basic Hospital, Medical, and Surgical Expense Policies? They have high deductibles. The benefits provided are usually equal to the actual expenses incurred. They usually have a stated limit for specific expenses. Benefits are provided for loss of income.
They usually have a stated limit for specific expenses.
The usual payment arrangement under a Preferred Provider Organization contract is: a fee-for-service basis. a flat monthly amount for each subscriber. reimbursement to the individual subscriber. any of the above.
a fee-for-service basis.
When a medical expense policy pays benefits on an indemnity basis, it pays a certain percentage of whatever the hospital room charges are for total hospital expenses, less a deductible a flat amount per day for hospital room and board only for surgery and miscellaneous hospital expenses
a flat amount per day for hospital room and board
What is included under the miscellaneous expense benefit? surgical expenses anesthesia physician fees post-operative care
anesthesia
Under the Basic Hospital Expense policy, what would not be covered under the miscellaneous expense benefit? anesthesia anesthesiologist use of the operating room drugs
anesthesiologist
How does a basic medical plan avoid small claims and keep the cost of premiums down? by utilizing deductibles and co-insurance by imposing benefit limits by paying only catastrophic medical expenses by providing a network of physicians and hospitals
by imposing benefit limits
In a Basic Hospital Expense policy, the miscellaneous expense limits are a multiple of what factor? daily room and board physician's expense surgical expense reasonable & customary
daily room and board
All of the following are eligible for Medicare except: those 65 or older dependents of those 65 or older folks with a chronic kidney disorder folks receiving Social Security Disability benefits
dependents of those 65 or older
The Blues have contractual relationships with which of the following? subscribers HMOs PPOs doctors and hospitals
doctors and hospitals
The miscellaneous expense benefit in a basic hospital expense policy will cover physician's bedside visits the administering of anesthesia drugs and medicine administered in the hospital hospital room and board
drugs and medicine administered in the hospital
Phil M. Cick is to have surgery and his physician states that the surgery can be performed either as an out patient or as an in-patient. Phil's policy will pay: the out-patient surgery only the in-patient surgery only either in or out patient everything only after a pre-certification has been given for the needed surgery
either in or out patient
The optional short term disability benefit that pays a lump sum for specified injuries is called the: hospital income benefit indemnity benefit supplement income benefit partial disability benefit
indemnity benefit
If all or part of a $500 deductible is offset by a Basic Medical policy, what type of deductible applies? integrated corridor flat split
integrated
Dread disease, travel accident, vision care, and hospital indemnity policies are all examples of: LTC policies limited risk policies special risk blanket policies
limited risk policies
A policyowner has just informed the agent that she is younger than what was stated in the policy. The agent should: write a new policy at the correct age immediately so there will be no gap in coverage. notify the insurance company for a possible review of the application. notify the insurance company for a possible adjustment of the policy. determine whether there has been any change in health since the application for the policy.
notify the insurance company for a possible adjustment of the policy.
Blue Cross and Blue Shield subscribers pay a set fee, usually each month, for medical services covered under the plan. This is describing: reimbursement approach capitation arrangement fee-for-service plan prepaid plan
prepaid plan
HMO's are known for stressing state sponsored health plans in hospital care and services health care services for government employees preventive medicine and early treatment
preventive medicine and early treatment
All of the following are types of deductible provisions associated with major medical policies except: corridor integrated stop loss flat
stop loss
Many major medical policies include a provision whereby when expenses reach a certain dollar amount, the insured no longer shares in the cost of expenses: the insurer pays 100% of remaining covered charges. This is referred to as the: maximum benefit benefit restoration coinsurance percentage stop-loss limit
stop-loss limit
A limited risk policy will pay for dread diseases that are terminal that are incurable such as cancer that are chronic
such as cancer
