14: Under which of the following organizations are the practicing providers compensated on a fee-for-service basis?
A Blue Cross/Blue Shield
B Open panel
C PPO
D HMO
PPOs contract on a Fee-for-service basis.Questions
1: A medical insurance plan in which the health care provider is paid a regular fixed amount for providing care to the insured and does not receive additional amounts of compensation dependent upon the procedure performed is called
A Indemnity plan.
B Reimbursement plan.
C Fee-for-service plan.
D Prepaid plan.
Under a prepaid plan, the health care providers are paid for services in advance, whether or not any services are provided. The amount paid to the provider is based upon the projected annual cost as determined by the provider.
Questions
1: In health insurance, if a doctor charges $50 more than what the insurance company considers usual, customary and reasonable, the extra cost
A Must be covered by the insurer.
B Counts toward deductible.
C Counts toward coinsurance.
D Is not covered.
An insurance company will pay the usual, reasonable, or customary amount for a given procedure based upon the average charge for that procedure.
3: What is the maximum amount of coinsurance in New York's major medical plans?
A 25%
B 35%
C 40%
D 50%
In the state of New York, coinsurance cannot exceed 25% for major medical plans.
7: Which of the following is NOT the purpose of HIPAA?
A To provide immediate coverage to new employees who had been previously covered for 18 months
B To guarantee the right to buy individual policies to eligible individuals
C To prohibit discrimination against employees based on their health status
D To limit exclusions for pre-existing conditions
HIPAA does not prohibit employers or providers from establishing waiting periods or pre-existing conditions exclusions, in which case the coverage to new employees would not be immediate.
12: An employee becomes insured under a PPO plan provided by his employer. If the insured decides to go to a physician who is not a PPO provider, which of the following will happen?
A The PPO will not pay any benefits at all.
B The insured will be required to pay a higher deductible.
C The PPO will pay the same benefits as if the insured had seen a PPO physician.
D The PPO will pay reduced benefits.
The group health plan will not pay the full amount charged by the non-PPO doctor.
3: What is the goal of the HMO?
A Providing free health services
B Limiting the deductibles and coinsurance to reduce costs
C Providing health services close to home
D Early detection through regular checkups
The goal of the HMO is early detection so members are encouraged to participate in regular checkups. In this way the HMO hopes to catch disease in its earliest stages when treatment has the greatest chance for success.
5: Which of the following is NOT provided by an HMO?
A Patient care
B Reimbursement
C Services
D Financing
Traditionally the insurance companies have provided the financing while the doctors and hospitals have provided the care. The HMO concept is unique in that the HMO provides both the financing and the patient care for its members. The HMO provides benefits in the form of services rather than in the form of reimbursement for the services of the physician or hospital.
Which of the following is NOT the purpose of HIPAA?
2: According to the Medical Loss Ratio (MLR), what is the minimum percentage of health coverage premium that must be applied to actual medical care in a large group health plan?
A 50%
B 75%
C 80%
D 85%
MLR requires insurance companies to spend at least 80% (for individual and small group markets) or 85% (for large group markets) of premium dollars on medical care and health care quality improvement, rather than on administrative costs.
3: What is the maximum age for qualifying for a catastrophic plan?
A 26
B 30
C 45
D 62
Young adults under age 30 and individuals who cannot obtain affordable coverage (have a hardship exemption) may be able to purchase individual catastrophic plans that cover essential benefits.
11: The Patient Protection and Affordable Care Act includes all of the following provisions EXCEPT
A Right to appeal.
B No lifetime dollar limits.
C Coverage for preventive benefits.
D Individual tax deduction for premiums paid.
The Act does not offer tax deductions for health insurance premiums. The Act does offer a tax credit, which is different from a tax deduction. All the other provisions are included in the Act.
Which of the following is NOT the purpose of HIPAA?
A To limit exclusions for pre-existing conditions
B To provide immediate coverage to new employees who had been previously covered for 18 months
C To guarantee the right to buy individual policies to eligible individuals
D To prohibit discrimination against employees based on their health status
HIPAA does not prohibit employers or providers from establishing waiting periods or pre-existing conditions exclusions, in which case the coverage to new employees would not be immediate.
10: An employee becomes insured under a PPO plan provided by his employer. If the insured decides to go to a physician who is not a PPO provider, which of the following will happen?
A The PPO will pay reduced benefits.
B The PPO will not pay any benefits at all.
C The insured will be required to pay a higher deductible.
D The PPO will pay the same benefits as if the insured had seen a PPO physician.
The group health plan will not pay the full amount charged by the non-PPO doctor.
11: Regarding a PPO, which of the following is correct when selecting a primary care physician?
A The insured may choose medical providers not found on the preferred list and still retain coverage.
B The insured is allowed to receive care from any provider, but if the insured selects a PPO provider, the insured will realize lower out-of-pocket costs.
C If a non-network provider is used, the insured's out-of-pocket costs will be higher.
D All of the above are correct
In a PPO, the insured does not have to select a primary care physician. Conversely, In a PPO, all network providers are considered "preferred," and you can visit any of them, even specialists, without first seeing a primary care physician. Certain services may require Plan precertification, an evaluation of the medical necessity of inpatient admissions and the number of days required to treat your condition.
10: All of the following are considered to be supplemental benefits under an HMO plan EXCEPT
A Prescription drugs.
B Preventive services.
C Long-term care.
D Mental health care.
HMOs have the option of providing one or more of the following supplemental benefits: long-term care, nursing services, home health care, prescription drugs, dental care, vision care, mental health care, and substance abuse services.
12: How is emergency care covered for a member of an HMO?
A A member of an HMO may receive care at any emergency facility, at the same cost as if in his or her own service area.
B HMOs have salaried member physicians, but they do not cover emergency care.
C An HMO emergency specialist will cover the patient.
D A member of an HMO can receive care in or out of the HMO service area, but care is preferred in the service area.
Emergency care must be provided for the member in or out of the HMO's service area. If emergency care is being provided for a member outside the service area, the HMO will be eager to get the member back into the service area so that care can be provided by salaried member physicians.
8: All of the following are characteristics of a Major Medical Expense policy EXCEPT
A Coinsurance.
B Low maximum limits.
C Deductibles
D Blanket coverage.
Major medical expense contracts are characterized by high maximum limits, blanket coverage, coinsurance, and a deductible.
A The gap of coverage for eligibility is a period of 63 or less days.
B An individual who was previously covered by group health insurance for 6 months is eligible.
C An individual who has used up COBRA continuation coverage is eligible.
D An individual who doesn't qualify for Medicare may be eligible.
All of these eligibility requirements are correct, except an individual who was previously covered for at least 6 months. HIPAA requires that the individual have a previous continuous creditable health coverage for at least 18 months.
4: Which of the following is NOT a characteristic or a service of an HMO plan?
A Providing care on an outpatient basis
B Contracting with insurance companies
C Providing free annual checkups
D Encouraging early treatment
HMOs seek to identify medical problems early by providing preventive care. They encourage early treatment and whenever possible provide care on an outpatient basis rather than admitting the member into the hospital. Contracts are between the insured and the HMO, not an insurance company.
5: All of the following may be excluded from coverage in a Major Medical Expense policy, EXCEPT
A Coverage provided under workers compensation.
B Emergency surgery.
C Custodial care.
D Cosmetic surgery.
These are all standard exclusions in a Major Medical Expense policy, except for emergency surgery.
8: An applicant has a history of heart disease in his family, so he would like to buy a health insurance policy that strictly covers heart disease. What type of policy is this?
A Dread disease coverage
B Single indemnity protection
C Term health coverage
D Scheduled benefit coverage
Limited coverage policies, such as dread disease policies, only cover specific medical costs, geared to a particular illness, such as cancer, or a field, like prescription drug or dental care.
11: What is the maximum amount of coinsurance in New York's major medical plans?
A 25%
B 35%
C 40%
D 50%
In the state of New York, coinsurance cannot exceed 25% for major medical plans.
12: Which of the following is NOT a cost-saving service in a medical plan?
A Risk sharing
B Denial of coverage
C Preventive care
D Second surgical opinions
Cost-saving services, also known as case management provisions, include the following: controlled access of providers, large claim management, preventive care, hospitalization alternatives, second surgical opinions, preadmission testing, catastrophic case management, risk sharing, and providing high quality of care.
13: How is emergency care covered for a member of an HMO?
A A member of an HMO may receive care at any emergency facility, at the same cost as if in his or her own service area.
B HMOs have salaried member physicians, but they do not cover emergency care.
C An HMO emergency specialist will cover the patient.
D A member of an HMO can receive care in or out of the HMO service area, but care is preferred in the service area.
Emergency care must be provided for the member in or out of the HMO's service area. If emergency care is being provided for a member outside the service area, the HMO will be eager to get the member back into the service area so that care can be provided by salaried member physicians.
15: What is NOT a benefit of a POS plan?
A With the Point-Of-Service plan the employees do not have to make a decision between the HMO or PPO plans that lock them in.
B It allows guaranteed acceptance of all applicants.
C It allows the employee to use an HMO provided doctor.
D It allows the employee to use a doctor not covered under the HMO.
A different choice can be made every time a need arises for medical services.
A The insured may choose medical providers not found on the preferred list and still retain coverage.
B The insured is allowed to receive care from any provider, but if the insured selects a PPO provider, the insured will realize lower out-of-pocket costs.
C If a non-network provider is used, the insured's out-of-pocket costs will be higher.
D All of the above are correct
In a PPO, the insured does not have to select a primary care physician. Conversely, In a PPO, all network providers are considered "preferred," and you can visit any of them, even specialists, without first seeing a primary care physician. Certain services may require Plan precertification, an evaluation of the medical necessity of inpatient admissions and the number of days required to treat your condition.
10: To be eligible under HIPAA regulations, for how long should an individual converting to an individual health plan have been covered under the previous group plan?
A 18 months
B 5 years
C 12 months
D 63 days
Under HIPAA regulations, to be eligible to convert health insurance coverage from a group plan to an individual policy, the insured must have 18 months of continuous creditable health coverage.
11: Under which of the following organizations are the practicing providers compensated on a fee-for-service basis?
A Open panel
B PPO
C HMO
D Blue Cross/Blue Shield
PPOs contract on a Fee-for-service basis.
12: All of the following may be excluded from coverage in a Major Medical Expense policy, EXCEPT
A Emergency surgery.
B Custodial care.
C Cosmetic surgery.
D Coverage provided under workers compensation.
These are all standard exclusions in a Major Medical Expense policy, except for emergency surgery.
Questions
3: When is the annual open enrollment for state insurance exchanges?
A December 1 through December 31
B January 1 through February 28
C December 1 through March 1
D November 1 through January 31
Annual open enrollment period is currently scheduled from November 1 through January 31.
4: The Patient Protection and Affordable Care Act includes all of the following provisions EXCEPT
A Coverage for preventive benefits.
B Individual tax deduction for premiums paid.
C Right to appeal.
D No lifetime dollar limits.
The Act does not offer tax deductions for health insurance premiums. The Act does offer a tax credit, which is different from a tax deduction. All the other provisions are included in the Act.
5: What is the maximum age for qualifying for a catastrophic plan?
A 26
B 30
C 45
D 62
Young adults under age 30 and individuals who cannot obtain affordable coverage (have a hardship exemption) may be able to purchase individual catastrophic plans that cover essential benefits.
7: According to the Medical Loss Ratio (MLR), what is the minimum percentage of health coverage premium that must be applied to actual medical care in an individual health plan?
A 25%
B 50%
C 80%
D 90%
MLR requires insurance companies to spend at least 80% (for individual and small group markets) or 85% (for large group markets) of premium dollars on medical care and health care quality improvement, rather than on administrative costs.
8: Which of the following is NOT a metal level of coverage offered under the Patient Protection and Affordable Care Act?
A Bronze
B Iron
C Gold
D Silver
The metal tiers of coverage required under the PPACA include platinum, gold, silver and bronze.
10: According to the Medical Loss Ratio (MLR), what is the minimum percentage of health coverage premium that must be applied to actual medical care in a large group health plan?
A 50%
B 75%
C 80%
D 85%
MLR requires insurance companies to spend at least 80% (for individual and small group markets) or 85% (for large group markets) of premium dollars on medical care and health care quality improvement, rather than on administrative costs.
11: Under the Affordable Care Act, a special enrollment period allows an individual to enroll in a qualified health plan within how many days of a qualifying event?
A 10 days
B 30 days
C 60 days
D 90 days
Unless specifically stated otherwise, individuals or enrollees have 60 days from the date of a triggering event to select a qualified health plan.
12: According to the PPACA rules, what percentage of health care costs will be covered under a bronze plan?
A 10%
B 30%
C 40%
D 60%
Under the bronze plan, the health plan is expected to cover 60% of the cost for an average population, and the participants would cover the remaining 40%.
14: Which of the following individuals will be eligible for coverage on the Health Insurance Marketplace?
A A U.S. citizen living abroad
B A permanent resident lawfully present in the U.S.
C Someone who has Medicare coverage
D A U.S. citizen who is incarcerated
To be eligible for health coverage on the Marketplace, the individual must be a U.S. citizen or national or be lawfully present in the United States, must live in the United States, and cannot be currently incarcerated. Medicare recipients are not eligible for coverage in the Marketplace.
15: To be eligible for tax credits under the ACA, individuals must have income that is what percent of the Federal Poverty Level?
A Between 100% and 400%
B Higher than 300%
C Less than 10%
D Between 10% and 100%
Legal residents and citizens who have incomes between 100% and 400% of the Federal Poverty Level (FPL) are eligible for the tax credits.