Ch. 14 - Health Providers

What is the maximum Social Security Disability benefit amount an insured can receive?

a. 50% of the insured's Primary Insurance Amount (PIA)

b. 75% of the insured's Primary Insurance Amount (PIA)

c. 100% of the insured's Primary Insurance Amount (PIA)

d. 100% of the insured's Primary Insurance Amount (PIA) minus any monies received from a retirement plan

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

a. usual, reasonable, and customary amount

b. excess charge

c. deductible

d. surplus fee

An organization that requires healthcare services to be provided by a network of physicians and hospitals is known as a(n)

a. PPO

b. HMO

c. POS

d. HDHP

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

a. excluded from coverage

b. partially covered

c. covered, but requiring a higher deductible and copay

d. subject to age restrictions

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

a. participants are normally small employers

b. participants must purchase all coverages the trust offers

c. participants are typically all in the same industry group

d. joinder agreement is issued to participants

Impatient psychiatric care is covered under Part A medicare Insurance for 190 days per

a. billing period

b. hospital visit

c. year

d. lifetime

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

a. participating provider

b. authorized provider

c. registered provider

d. admitted provider

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

a. Stress reduction

b. Routine physicals

c. Smoke cessation programs

d. Diagnostic testing services

Which of the following does NOT fall under "hospital care" in a typical health maintenance organization (HMO) plan?

a. Private duty nursing

b. Inpatient X-rays

c. Inpatient mental health care

d. Inpatient lab services

Karen is a health maintenance organization (HMO) subscriber. Who provides all of her preventative and routine care?

a. Primary care physician

b. Provider specialist

c. Preventative coordinator

d. HMO director

Rick is a disabled worker receiving Social Security benefits. What benefits are his wife and dependent children eligible for?

a. No benefits

b. Spouse is eligible for an income benefit but the children are not

c. An income benefit which is a percentage of his primary insurance amount

d. An income benefit which equals his entire primary insurance amount

Individuals who participate in an HMO plan are called

a. certificate holders

b. subscribers

c. policyowners

d. beneficiaries

What is a major difference between private commercial insurers and HMO's?

a. An HMO pays claims on a fee-for-service basis

b. A private commercial insurer typically has fewer health provider choices

c. An HMO combines medical care delivery and funding in one organization

d. A private commercial insurer only offers individual coverage

A characteristic of preferred provider organizations (PPO) is

a. PPOs operate like an HMO on a prepaid basis

b. if service is obtained outside the PPO, benefits are reduced and costs increase

c. PPOs are generally public in nature rather than private

d. Health care providers themselves are barred from forming a PPO due to conflict of interest

Which of the following is NOT a reason the government provides insurance?

a. stimulate economic development

b. reduce fraudulent claims

c. ensure social needs are being met

d. increase availability of health coverage

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

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?

a. loss of income that results from a workplace injury is not covered by worker's compensation

b. worker's compensation claims require a lengthy elimination period before benefits are paid

c. worker's compensation benefits are taxable and additional coverage needs to be purchased to offset the tax

d. the benefits arising from a worker's compensation claim could be inadequate to replace the loss of income

Medicare Part A typically covers

a. inpatient drugs

b. custodial care

c. disability income

d. respite care

Employees generally receive workers compensation benefits for

a. only medical expenses due to occupational accidents

b. employment termination

c. lost wages and medical expenses due to occupational accidents

d. only lost wages due to accidents that occur on the job

Inpatient psychiatric care is covered under Part A Medicare Insurance for 190 days per

a. billing period

b. hospital visit

c. year

d. lifetime

Medicare will cover a maximum of how many days per benefit period in a skilled nursing facility?

a. 10 days

b. 30 days

c. 60 days

d. 100 days

Federally qualified HMO's must offer

a. dental coverage

b. urgent care

c. family planning services

d. custodial care

Emily is disabled. In order to become eligible for Social Security disability income benefits, she must be

a. expected to live no longer than 12 months

b. partially insured, according to Medicaid

c. fully insured, according to Social Security

d. married with children

A MET third-party administrator may NOT perform which of the following functions?

a. claims processing

b. marketing the plan

c. underwriting the plan

d. insuring the plan

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

a. military families

b. Social Security recipients

c. permanent disabled individuals

d. children

What is the eligibility requirement for Medicare Part B?

a. must be uninsurable

b. must be eligible for Medicare Part A

c. must be retired

d. must be totally disabled

Tim had an on-the-job accident and collects benefits from his individual disability income policy. Which factor could possibly reduce these benefits?

a. state and federal income taxes

b. benefits he receives from workers compensation

c. total household income

d. assistance he receives from friends and family

Third-party administration has become fairly common in accident and health insurance due to the growth of

a. the Affordable Care Act

b. self-funding of benefits

c. health savings accounts

d. Medicaid

Which of the following is NOT true of a preferred provider plan?

a. If service is obtained outside the preferred provider plan, benefits are reduced and costs increase

b. Members of the preferred provider plan select from among the preferred providers for needed services

c. Hospitals can only initiate preferred provider plans

d. Preferred provider plans can include dental care

What can be expected when a preferred provider organization (PPO) patient decides to use a non-PPO?

a. higher out-of-pocket expenses

b. lower out-of-pocket expenses

c. 100% coverage

d. no coverage

Where does the primary funding for Medicare Part A come from?

a. private funding

b. insurance company funding

c. state funding

d. federal payroll and self-employment taxes

Which of the following health plans pay benefits on a pre-paid service basis?

a. Medicare

b. Medicaid

c. Group medical expense plans

d. HMO

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

a. HMO plan

b. POS plan

c. PPO plan

d. major medical plan

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?

a. Medicare

b. Medicaid

c. Medicare Supplement

d. Her employer's group accident and health plan

Which statement is true about a permanent disability under workers compensation coverage?

a. employee is expected to return to work within 6 months

b. coverage includes nonoccupational injuries

c. employee is expected to make a full recovery

d. coverage excludes nonoccupational injuries

The grouping of two or more small employers in order to obtain group health insurance at a favorable rate is called a multiple employer

a. grouping

b. trust

c. alliance

d. corporation

Medicare Part A covers which type of care?

a. skilled nursing facility care

b. custodial care

c. respite care

d. intermediate nursing facility care

In a staff model HMO, enrollees normally have which of the following pharmacy options available to them?

a. mail-order pharmacy

b. in-house pharmacy

c. captive pharmacy

d. network pharmacies

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?

a. It is available through application to Homeland Security

b. It is available through application to Social Security

c. He is automatically enrolled through this employer

d. He is not eligible until he starts receiving social security retirement income

Medicaid will pay for nursing home expenses under what condition?

a. must have permanent kidney failure

b. must be age 65 or older

c. must be receiving Social Security disability benefits

d. must have financial need

The coinsurance for skilled nursing facility services covered by Medicare after the 100% Medicare coverage ends is

a. 15% of the approved amount

b. 30% of the approved amount

c. a percentage of the approved amount

d. a flat dollar amount per day

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

a. Preferred Provider Organization (PPO)

b. Health Maintenance Organization (HMO)

c. Designated Provider Organization (DPO)

d. Professional Service Organization (PSO)

All parts of the Medicare program (except for public information and enrollment) are administered by which federal agency?

a. the ACA

b. the Social Security Administration

c. the Department of Homeland Security

d. the Centers for Medicare and Medicaid Services

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

a. 10 quarters

b. 20 quarters

c. 30 quarters

d. 40 quarters

Part A Medicare includes coverage for all of the following services EXCEPT

a. first 60 days of hospitalization

b. 120 days of Skilled Nursing Facility care

c. hospice care

d. inpatient mental health care limited to 190 days in a lifetime

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

a. capitation level

b. primary level physician

c. closed panel

d. deductible level

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

a. Department of Health and Aging

b. Social Security Administration

c. Centers for Medicare and Medicaid Services

d. Department of Homeland Security

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?

a. unemployment

b. workers compensation

c. Medicaid compensation

d. Social Security Disability

Individuals seeking Social Security disability income benefits must have a disability that will eventually lead to death, or be expected to last at least

a. 3 months

b. 6 months

c. 9 months

d. 12 months

An HMO prescription drug plan is generally characterized by

a. generic drugs only

b. annual deductibles

c. drugs dispensed through participating pharmacies

d. drugs dispensed through online pharmacies

Skilled nursing facility expenses are sometimes coved by , but ONLY if the insured was hospitalized prior to entering the facility.

a. HMOs

b. Medicare

c. Medicaid

d. Medicare Supplements

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

a. January through March of each year

b. October through December of each year

c. Six months after the individual's birthday month of each year

d. Three months after the individual's birthday month of each year

At what age do most people become eligible for Medicare?

a. 59 1/2

b. 62

c. 65

d. 72

Medicare Part A does NOT provide coverage for

a. inpatient room and board

b. inpatient prescription medication

c. first 3 pints of blood

d. skilled nursing facility care

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

a. neurologist

b. HMO administrator

c. HMO director

d. gatekeeper

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

a. notices symptoms

b. enters a hospital

c. becomes eligible for Medicare

d. is diagnosed of an illness

Medicare can be described as

a. a supplemental income source for individuals over the age of 65 or permanently disabled

b. a state health program for individuals over the age of 65 or permanently disabled

c. a federal health program for individuals with financial need

d. a federal health insurance program for individuals over the age of 65 or permanently disabled

Which of these procedures is NOT designed for ambulatory care centers?

a. inpatient surgery

b. vaccinations

c. outpatient surgery

d. physical examinations