Chapter 5 Medical Plans
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- 1.A Health Insurance plan involves financing, managing, and delivery of Health Care services. This describes what type of plan?
- A.
Self-Insurer plan
- B.
Preferred Care plan
- C.
Limited Care plan
- D.
Managed Care plan
- 2.Who determines the eligibility and contribution limits to a Health Reimbursement Account?
- A.
The employee
- B.
The employer
- C.
The employee’s account
- D.
The employee’s credit
- 3.When will a PPO not pay the full amount of a charge?
- A.
Never
- B.
If a Non PPO doctor is used for services
- C.
If the service fee is too high
- D.
When the gatekeeper provides a referral for a specialist
- 4.Which of the following is a payment system for Health Care where the provider is paid for each service given?
- A.
Pre-paid visit basis
- B.
Lump sum payment
- C.
Fee for service
- D.
Premium payment
- 5.Which of the following is not a primary characteristic of a Major Medical Plan?
- A.
Coinsurance
- B.
Deductible
- C.
No catastrophic protection
- D.
High maximum limits
- 6.How are PPO physicians paid?
- A.
On a prepaid basis
- B.
A fee for each service they provide
- C.
Monthly
- D.
Only when providing services in their geographic area
- 7.All of the following are exclusions from Major Medical policies, except:
- A.
Custodial Care
- B.
Self-inflicted injuries
- C.
Catastrophic loss
- D.
Injuries from an act of war
- 8.What kind of benefits are in Eligible Health plans?
- A.
High Maximum benefits
- B.
Low Maximum benefits
- C.
Deductible benefits
- D.
Indemnity benefits
- 9.What is the main purpose of getting a referral from a gatekeeper, so a subscriber can see a specialist?
- A.
To increase costs
- B.
To contain costs
- C.
To provide more services
- D.
To provide preventive care
- 10.A pre-existing condition is a condition for which the employee has sought medical advice, diagnosis, or treatment within the previous __ months.
- A.
24
- B.
6
- C.
9
- D.
12
- 11.Which of the following is NOT true of Basic Medical plans?
- A.
First-dollar coverage
- B.
No deductibles
- C.
Coverage for catastrophic medical expenses
- D.
Low dollar limits
- 12.Major Medical Insurance Plans that cover expenses in and out of Medical facilities, are called?
- A.
Eligible Plans
- B.
Deductible Plans
- C.
Comprehensive Plans
- D.
Indemnity Plans
- 13.Which of the following is an advance utilization management tool to determine if a procedure is covered under a Health plan?
- A.
Concurrent Review
- B.
Prospective Review
- C.
HIPPA Review
- D.
Guaranteed Issue Review
- 14.Which of the following describes the purpose for a Certificate of Coverage?
- A.
To reduce the 6 month waiting period for pre-existing conditions
- B.
To reduce the 5 month waiting period for pre-existing conditions
- C.
To reduce the 1 year waiting period for pre-existing conditions
- D.
To reduce and discontinue coverage
- 15.If your Health Care plan has characteristics of an HMO and a PPO, what type of plan do you have?
- A.
HIPAA
- B.
POS
- C.
MET
- D.
PPM
- 16.Crystal owns a Mediacl Expense Plan that contains a 60/40 coinsurance after the deductible is met. If a claim was filed and $7,200 in costs remained after Crystal met the $200 deductible:
- A.
The insurer would pay $2,880, and Crystal would pay $4,320
- B.
The insurer would pay $4,440, and Crystal would pay $2,960
- C.
The insurer would pay $2,960, and Crystal would pay $4,440
- D.
The insurer would pay $4,320, and Crystal would pay $2,880
- 17.What is the best definition of a Limited Accident Policy?
- A.
Provides specific benefits for specific injuries from specific causes.
- B.
Only covers for a limited time after the accident.
- C.
Limited in geographical scope
- D.
All answers are correct
- 18.Insurers include provisions in contracts to help reduce unnecessary claims and the overpayment of claims. Which of the following is not one of those provisions?
- A.
Concurrent Review
- B.
Consideration Clause
- C.
Mandatory Second Surgical Clause
- D.
Ambulatory Services
- 19.Which of the following is a Case Management Provision used by insurers to monitor hospital stays?
- A.
Case Management
- B.
Concurrent Review
- C.
Managed Health Review
- D.
Precertification
- 20.Under HIPAA, coverage may be nonrenewed for all of the following reasons, except:
- A.
Nonpayment of premium
- B.
Frequency of claims
- C.
Noncompliance with plan provisions
- D.
Participation requirements not fulfilled
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