Chapter 5 Medical Plans

20 Questions | Total Attempts: 977

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Chapter 5 Medical Plans

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Questions and Answers
  • 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