Chapter 5 – Health Insurance Providers

20 June 2024
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question
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 Ā½ - When becoming eligible for Medicare
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When becoming eligible for Medicare
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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
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Falling below the federal poverty level
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How much does Medicare Part B pay for physician fees? - 40% - 60% - 80% - 100%
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80%
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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
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MEWA
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An accident and health policy that provides reimbursement benefits make them payable to the - Provider - Facility proving service - Insured - Insured's spouse
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Insured
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Medicare Part A covers - Outpatient services - Doctor's fees - Inpatient hospital stay - Prescription drugs
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Inpatient hospital stay
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Which of these will typically authorize treatment from a specialist? - Administrator - Policyowner - Insurance company - Gatekeeper
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Gatekeeper
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A medical provider that accepts Medicare Assignment must - Accept payment based upon a defined Medicare schedule and bill 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
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Accept payment based upon a defined Medicare schedule as payment in full
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Donna and Mary were racing bicycle 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 insured. Who would most likely be covered under Workers' Comp? - John - Mary - Jon and Mary - Neither of them
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John
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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
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A 70-year old NOT eligible for Social Security
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Medicare Part B covers - Long-term care - Hospital room and board - Doctor's charges - Prescription drugs
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Doctor's charges
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A closed network plan offers a primary physician copay of $25. If a subscriber chooses a primary care physician out of the network, the subscriber will likely pay - $0 - $25 - 100% of the billed amount - 100% of the allowed amount
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100% of the billed amount
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How is Medicare Part B funded? - Employer taxes - Payroll taxes - User premiums - General tax revenue and user premium
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General tax revenue and user premium
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What is Medicare Part B also known as? - Medicare supplement - Supplementary medical insurance - Comprehensive insurance - Medicaid
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Supplementary medical insurance
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An individual covered under a Blue Cross Blue Shield plan is called a(n) - Participant - Subscriber - Policyowner - Insured
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Subscriber
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At what age will a person normally enroll with an insurance carrier under a Part C Medicare Advantage Plan? - Age 59 Ā½ - Age 60 - Age 62 - Age 65
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Age 65
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Funding for Medicare Part B is partially provided by - Municipal bonds - State bonds - Private insurers - User premiums
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User premiums
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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
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Will be the secondary insurer and pay for claims not fully covered by the group plan
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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
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Provides a greater choice of providers
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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
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The insurer will pay a reduced amount
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The purpose of the Coordination of Benefits provision in group accident and health plans is to - Avoid overpayment of claims - Reduce out-of-pocket costs - Reduce adverse selection - Lower the cost of premiums
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Avoid overpayment of claims
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Medicaid is intended for - People with kidney failure - People age 65 and older - Unemployed people - Poverty stricken people
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Poverty stricken people
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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
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Poor people
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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
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Group HMO
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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
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100 days
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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 physical gives a referral
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Care is covered
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What type of injury would NOT be covered under a health insurance policy? - Accidental - Work-related - Sports-related - Recreational
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Work-related
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A doctor who accepts Medicare Assignment agrees to which of the following? - Doctor may charge up to a maximum of 15% more than Medicare pays for the service - Doctor is not bound by Medicare's limitations on charges - Doctor cannot charge more than Medicare's scheduled coverage - Doctor bills the Medicare beneficiary directly for services performed
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Doctor cannot charge more than Medicare's scheduled coverage
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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
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Prepaid
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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
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Must have Medicare coverage
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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 Group (MPG) - Fraternal Benefit Society
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Multiple Employer Welfare Arrangement (MEWA)
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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
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Occupational disease
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Medicare provides coverage for each of the following EXCEPT - Hospital room and board - Doctor and surgeon services - Prescription drugs - Custodial care
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Custodial care
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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
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Receive matching funds to expand public assistance programs
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Which of the following is Medicare Part B also known as? - Hospital insurance - Medical insurance - Long-term care insurance - Medigap
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Medical insurance
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A health care provider claim may be settled using which of following payment methods? - Litigation - Unfair claim settlement - Fee-for-service - Prepaid expense
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Fee-for-service
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Which of the following is NOT taken into consideration when determining eligibility for Medicare benefits? - Chronic kidney disease - Income - Age - Social security disability
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Income
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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 3
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January 1 through March 31