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Wisconsin Accident and Health Insurance Exam 2
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Wisconsin Accident and HealthInsurance Exam 2
Alan is an enrollee of a health maintenance organization (HMO) which uses a
gatekeeper system. If there ever comes a time when he needs emergency
health services, what should he do?
Receive permission from the primary physician to begin treatment.
Call the HMO to verify coverage.
Proceed to the nearest emergency room.
Contact the HMO for a listing of approved providers. - -Proceed to the
nearest emergency room.
-What is a major difference between private commercial insurers and
HMO's?
An HMO pays claims on a fee-for-service basis.
A private commercial insurer typically has fewer health provider choices.
An HMO combines medical care delivery and funding in one organization.
A private commercial insurer only offers individual coverage. - -An HMO
combines medical care delivery and funding in one organization
-Which of the following health plans pay benefits on a pre-paid service
basis?
Medicare.
Medicaid.
Group medical expense.
HMO. - -HMO
-In a staff model HMO, enrollees normally have which of the following
pharmacy options available to them?
Mail-order pharmacy.
In-house pharmacy.
Captive pharmacy.
Network pharmacies. - -In-house pharmacy.
-Inpatient psychiatric care is covered under Part A Medicare for 190 days per
Admission.
Year.
Benefit period.
,Lifetime. - -Lifetime.
-An HMO prescription drug plan is generally characterized by
Generic drugs only.
Annual deductibles.
Drugs dispensed through participating pharmacies.
Drugs dispensed through online pharmacies. - -Drugs dispensed through
participating pharmacies.
-A characteristic of preferred provider organizations (PPO) is
PPOs operate like an HMO on a prepaid basis.
If service is obtained outside the PPO, benefits are reduced and costs
increase.
PPOs are generally public in nature rather than private.
Health care providers themselves are barred from forming a PPO due to
conflict of interest. - -If service is obtained outside the PPO, benefits are
reduced and costs increase.
-Individuals who participate in an HMO plan are called
Certificate holders.
Subscribers.
Policyowners.
Beneficiaries. - -Subscribers.
-Tim had an on-the-job accident and collects benefits from his individual
disability income policy. Which factor could possibly reduce these benefits?
State and federal income taxes.
Benefits he receives from workers compensation.
Total household income.
Assistance he receives from friends and family. - -Benefits he receives from
workers compensation.
-Which of these procedures is NOT designed for ambulatory care centers?
Inpatient surgery.
Vaccinations.
Outpatient surgery.
Physical examinations. - -Inpatient surgery.
-Specialty care is provided by which of the following health maintenance
organization (HMO) providers?
,Neurologist.
HMO administrator.
HMO director.
Gatekeeper. - -Neurologist.
-A MET third-party administrator may NOT perform which of the following
functions?
Claims processing.
Marketing the plan.
Underwriting the plan.
Insuring the plan. - -Marketing the plan.
-The coinsurance for skilled nursing facility services covered by Medicare
after the 100% Medicare coverage ends is
15% of the approved amount.
30% of the approved amount.
A percentage of the approved amount.
A flat dollar amount per day. - -A flat dollar amount per day.
-Ken is age 65 and has 2 years until he receives Social Security retirement
income benefits. At his current age, which is true about Medicare Part A
Hospital Insurance coverage?
It is available through application to Homeland Security.
It is available through application to Social Security.
He is automatically enrolled through his employer
He is not eligible until he starts receiving social security retirement income. -
-It is available through application to Social Security.
-Third-party administration has become fairly common in accident and
health insurance due to the growth of
The Affordable Care Act.
Self-funding of benefits.
Health savings accounts.
Medicaid. - -Self-funding of benefits.
-Tonya has been diagnosed with kidney failure and is covered by group
accident and health insurance through her large employer. Which of these
accident and health plans will be primary during the months immediately
following her diagnosis?
Medicare.
Medicaid.
, Medicare Supplement.
Her employer's group accident and health plan. - -Her employer's group
accident and health plan.
-Employees generally receive workers compensation benefits for
Only medical expenses due to occupational accidents.
Employment termination.
Lost wages and medical expenses due to occupational accidents.
Only lost wages due to accidents that occur on the job - -Lost wages and
medical expenses due to occupational accidents.
-Where does the primary funding for Medicare Part A come from?
Private funding.
Insurance company funding.
State funding.
Federal payroll and self-employment taxes. - -Federal payroll and self-
employment taxes.
-What is the maximum Social Security Disability benefit amount an insured
can receive?
50% of the insured's Primary Insurance Amount (PIA).
75% of the insured's Primary Insurance Amount (PIA).
100% of the insured's Primary Insurance Amount (PIA).
100% of the insured's Primary Insurance Amount (PIA) minus any monies
received from a retirement plan. - -100% of the insured's Primary Insurance
Amount (PIA).
-Medicare can be described as
A supplemental income source for individuals over the age of 65 or
permanently disabled.
A state health program for individuals over the age of 65 or permanently
disabled.
A federal health program for individuals with financial need.
A federal health insurance program for individuals over the age of 65 or
permanently disabled. - -A federal health insurance program for individuals
over the age of 65 or permanently disabled.
-Medicare Part A typically covers
inpatient drugs.
custodial care.
disability income.
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