Deck 4: Types and Sources of Health Insurance

Question 1

Most health insurers ask that patients pay a portion (or percentage)of the charge for professional services.This charge is commonly referred to as:

A) usual, customary, and reasonable (UCR).
B) coinsurance.
C) deductible.
D) reimbursement.

Answer 1

coinsurance.

Question 2

People who are covered under managed care plans are commonly referred to as:

A) enrollees.
B) policyholders.
C) charter members.
D) covered entities.

Answer 2

enrollees.

Question 3

A special tax shelter set up for the purpose of paying medical bills is a/an:

A) indemnity plan.
B) managed care plan.
C) tax shelter contract.
D) medical savings account.

Answer 3

medical savings account.

Question 4

The traditional kind of health insurance wherein patients can choose any provider or hospital they wish and change physicians at will is:

A) indemnity.
B) fee-for-service.
C) managed care.
D) both a and b

Question 5

The dollar amount that a patient must pay each year before his or her insurance benefits begin is called a/an:

A) dividend.
B) copayment.
C) deductible.
D) reimbursement.

Question 6

A family physician,internist,obstetrician-gynecologist,or pediatrician who is usually the patient's first contact for healthcare defines a/an:

A) participating provider.
B) initial provider.
C) primary care physician.
D) principal provider.

Question 7

The monthly (or periodic)fee paid for health insurance is commonly called a:

A) stipend.
B) premium.
C) penalty.
D) disbursement.

Question 8

An insurance contract made with a business entity that covers its employees under a single policy is called a/an:

A) group contract.
B) business contract.
C) equilateral contract.
D) managed care contract.

Question 9

A _____ provider is one who contracts with the insurer,agreeing to abide by certain rules and regulations of that carrier.

A) participating
B) nonparticipating
C) managed healthcare
D) fee-for-service

Question 10

A network of doctors and hospitals that shares responsibility for managing healthcare needs of a minimum of 5000 Medicare beneficiaries for at least 3 years.

A) Accountable Care Organization
B) Health Insurance Exchange
C) Health Savings Plan
D) Health Maintenance Organization

Question 11

Medical illnesses or injuries that a patient has before the purchase of a health insurance policy are called:

A) riders.
B) exemptions.
C) policy precursors.
D) preexisting conditions.

Question 12

When an individual is eligible for coverage under two different health insurance policies,____________________ limits the total benefits an insured individual can receive from both plans to not more than 100% of the allowable expenses.

A) COBRA
B) coordination of benefits
C) the health reimbursement arrangement
D) medical necessity

Question 13

A health insurance model intended to create a more organized and competitive market by offering consumers plan choices with common rules as to how the plan is offered,its cost,etc.defines a/an:

A) Accountable Care Organization.
B) health insurance exchange.
C) health savings account.
D) managed care organization.

Question 14

The type of insurance that covers a broad range of services,including nursing home care,assisted living facilities,certain types of home healthcare,and adult day care.

A) Accountable Care Organization
B) Health insurance exchange
C) Health savings account
D) Long-term care insurance

Question 15

Most third-party payers do not pay for medical services that are:

A) diagnostic in nature.
B) considered outdated.
C) not medically necessary.
D) provided in another state.

Question 16

When an individual purchases a healthcare policy from a commercial insurer,he or she is said to have a/an:

A) unenforceable contract.
B) individual policy.
C) managed care plan.
D) both b and c

Question 17

Fee-for-service health insurance policies generally limit what a patient must pay on their own,which is referred to as the:

A) cap rate.
B) maximum pay.
C) limited amount.
D) out-of-pocket maximum.

Question 18

Health insurance payments are sometimes based on what is referred to as:

A) UCR rates.
B) individual state rates.
C) average national rates.
D) international rates.

Question 19

The level of health plan which is most like the former "basic" coverage is called the:

A) bronze plan.
B) silver plan.
C) gold plan.
D) platinum plan.

Question 20

The form that is most commonly used today for insurance claims submitted on paper is the:

A) UB-04.
B) CMS-1500.
C) HCFA-1490.
D) HCPCS 1090.

Question 21

After the yearly deductible is met,the patient typically shares the bill with the insurance company in an arrangement called ____________________.

Question 22

Illnesses or injury that occurred before the start of a health insurance contract.

Question 23

SSDI is an insurance program that only individuals older than 65 can qualify for.

Question 24

Long-term care insurance covers nursing home care.

Question 25

TRICARE is the U.S.military's comprehensive healthcare program for active duty and retired personnel.

Question 26

A special tax shelter set up for the purpose of paying medical bills.

Question 27

Traditional healthcare in which patients can choose any provider they want (including specialists)and change physicians at any time.

Question 28

The part of a provider's charge that the insurance carrier will allow as a covered expense.

Question 29

The flexible spending account (FSA)is an IRS Section 125 _____________.

Question 30

The amount the insured must pay before insurance coverage begins is referred to as the ________________.

Question 31

Define the Consolidated Omnibus Budget Reconciliation Act (COBRA),who it applies to,and the provisions contained within this law.

Question 32

A law that provides continuation of group health coverage when an individual leaves his or her place of work.

Question 33

A periodic fee that is paid to an insurer for healthcare coverage.

Question 34

Describe the difference between a participating provider and a nonparticipating provider and how the difference affects fees.

Question 35

Flexible spending accounts are "cafeteria" plans,meaning premiums are deducted from the employee's wages before withholding taxes are deducted.

Question 36

Name the two basic types of health insurance plans today,and list the three primary ways these two types of plans differ in their basic approach to paying healthcare benefits.

Question 37

Disability insurance is the same as workers' compensation.

Question 38

Medicare supplement policies are frequently called Medigap policies.

Question 39

Medicaid is administered solely by the federal government.

Question 40

A provider who is under no contractual agreement with the insurer to accept reimbursement as payment in full.

Question 41

Under a health reimbursement arrangement (HRA),employees must provide the funds for all medical expenses incurred.

Question 42

Individuals who prefer not to enroll in original Medicare can purchase supplemental policies called Medigap or Medicare Supplement plans.

Question 43

The Affordable Care Act now makes it illegal for health insurance companies to deny coverage to any applicant with a preexisting condition.

Question 44

When medical services,procedures,or supplies meet specific criteria and are proper and needed for the diagnosis or treatment of a patient's medical condition,they are said to be "medically necessary."

Question 45

Under COBRA,employees working for qualifying employers can continue their healthcare coverage indefinitely when they leave or lose their job.

Question 46

HRAs,also known as "health reimbursement accounts," are a type of healthcare plan that reimburses employees for certain qualifying medical expenses.

Question 47

UCR fees for commercial insurers are established by the federal government.

Question 48

The "birthday rule" is an informal procedure used to determine which plan is "primary" when individuals are listed as dependents on more than one policy.