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213 Cards in this Set
- Front
- Back
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Jerry belings to an HMO. His primary care physiscian receives a set amount monthly to provide care for jerry, regardless of how often the physician sees Jerry.
fee for service, reimbursement, capitation |
capitation |
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Maryanne belongs to a PPO. Her primary care physician receives a payment every time Maryanne receives care from her.
fee for service, reimbursement, capitation |
fee for service |
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Harold has a traditional medical expense insurance policy. WHen he visits his doctor, Harold files a calim. The insurer sends Harold a payment based onthe submitted charges.
fee for service, reimbursement, capitiation |
reimbursement |
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Six differnet common types of limited health policies: |
Hospital Income Travel accident Accident only Blanket Credit Dread Disease |
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Tax-favored savings plan:
Employers
a. flexible spending accounts b. health savings accoutns c. health reimbursments |
c |
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Tax-favored savings plan:
employees
a. flexible spending accounts b. health savings accounts c. health reimbursments |
a |
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tax-favored savings plan:
either employer or employee
a. flexible spenidng accounts b. health savings accounts c. health reimbursements |
b |
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SS benefits: Acronym and meanings |
OASDI+Med
Old Age Survivors Disabilty Income Medicare |
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Julia has a policy that will pay any expenes she incurs as the result of in-hospital medical treatment as well as some of the expenses she incurs on an outpaitent basis. She probably has:
a. disability income policy b. medical expense insurance policy c. LT care policy d. Hospital income insurance policy |
B |
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The main differenc ebetween traditional health insurance arrangements and HMOs is that:
a. traditional health insurance companies provide both the health care service and the health care finance,but HMO's provide only health care financing. b. traditional companie sprovide both and HMO's provide only service c. HMOs providie both, traditional provide only financing d. HMOs provide bother, traditional provide only the service |
C |
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wof types of health care insurers is an example of a producers' cooperative?
a. urgent care center b. blue cross/blue shield c. commercial insurer d. skilled nursing facility |
B |
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HMO contracts wih an independent medical group that specializes in a variety of medical services in order to privide those servicies t oHMO subscribers: structured as:
a. staff model HMO b. network model HMO c. group model HMO d. individual practice association model HMO |
C |
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HMO contracting physicians are paid employees working ont he staff of the HMO, operating in a clinic setting at the HMO's physical facilities. operates as:
a. staff model hmo b. network model hmo c. group model hmo d. individual practice association model hmo |
A |
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HMO contracts with 14 medical groups to increase accessibility to providers as a convenience for subscribers. Each of the medical groups is paid on a capitation basis to provide services to it's subscribers. Operates as:
a. staff model hmo b. network model hmo c. group model hmo d. individual practice association model hmo |
B |
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HMO started by a group of individual physicians, and each physician operates out of his or her own office. The physicians are paid on a fee for sevice basis withthe fees negotiated in advance. operates as:
a. staff model hmo b. network m hmo c. group modeel hmo d. indviudal practice association model hmo |
D |
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HMO requires that she receve health care services from a specified, limited number of health care providers chosen by HMO:
a. open panel b. closed panel c. choice panel d. guarded panel |
B |
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aof are examples of managed care plans except:
a. health maintenance organizations b. perferred provider organizations c. indemnity arrangements d. point-of-service plans |
c |
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A method of pmt in which a provider is paid a specific fee monthly for each subscriber is known as
a. indemnity b. fee-for-servicie c. managaed care d. capitation |
D |
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best cleaners has a health plan that provides its employees with a high-deductibel medical indemnity plan and an account funded by the business, which employees can use to pay for medical expenses throughout the year or withdraw at the end of the year as taxible income. plan is probably:
a. cafeteria plan b. medical savings account c. multiple employer trust d. third party admin |
B |
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wof individuals would probably qualify for SS disability benefits?
a. ski instructor who breaks leg b. ill w/ viral infection out 6 months of work c. mechanic who loses his dominant hand ina n accident d. early -onset altzheimers unabel to remember how to get to work |
D |
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under workers comp, the permannet total disability benefit, while subject to minimum and maximum dollar amounts is generally:
a. 50% of weekly wages b. 66.66% of weekly wages c. 70.5% of weekly wages d. 75% |
B |
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under workers comp, individuals with partial disabilities who are able to perform some work are eligibel to receieve:
a. nothing b. 2/3rds of weekly wages, sbj to minim and max dollar amts c. entire wage loss, sbjt to minimum and max dollar amts d. percentage of the wage losss sbj to minimum and maximum dollar amounts |
D |
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health insurance coverage never applies until
a. policy is delivered b. u/w decision is made c. application is reviewed by u/w d. insured has paid for policy |
D |
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Once a health insurance policy becomes effective, unless i tis cancled, it will stay in force for
1 yr, 6 mo, the lenth of the term, indefinite period |
length of the term |
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an insurer might mequire personal delivey:
a. to ensure the policy goes to the right person b. for verification of the continued good health of hte insured at the time of delivery c. to ensure the correct policy i sdelivered d. to verify information listed on the app |
B |
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no loss/no gain legislation requires a replacing policy to:
a. have exactly the ame premium as the policy it replaces b. have exactly the same limits of coverage as the policy it replaces c. continue to pay claims ongoing under the policy it replaces d. continue to use the same producer to manage the policy as the policy it replaces |
C |
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a statement that ensures benfits provided under the old policy will continue under the new policy is:
a. a transfer of benfits statemnt b. a continuation of benefits statement c. a preexisting conditions covg statment d. a replacemnt statement |
A |
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restrictions applying to the repalcement of medicare usppliment policies are:
a. often less restrictive than regulations applying ot the replacement of other policies b. generallythe same as regulations applying to the replacemnt of other policies c. often more restrictive than regualtions applying ot the replacement of other policies d. prohibited entirely by federal law |
c |
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Barb had a terrible skiing accident resulting in a badly broken leg which required hospitalization. She had an indivdual hospital expense policy that provided reimbursement for coverd expenses. In accordance with the amndatory provisions of her policy, barb had __ days to give Notice of Claim. The insurer then had __ days ot provide her with Claim forms. She had a total of __ days after her accident to provide Proof of Loss. The payment of claims provision directs the insurer to pay the benefits to the ___ and the Time Payment of Claims provision tells them to pay ____. If the isnurer fails to pay her claim, Barb may take legal action no sooner than __ days and no later than __ years after filing her proof of loss. |
20 days (notice of claim) 15 days (claim form) 90 days (proof of loss) insured (pmt of claims) Immediately (time of pmt of claims) 60 days (legal action) 3 years (legal action) |
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A policy must automatically be considered reinstated by an insurer __ days after submitting any required application and/or premium |
45 |
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Covg for sickness by a reinstated policy will begin after a waiting period of ___ days. |
10 |
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accordin to the entire contract provision, the entire contract included aof except:
a. insurance policy b. premium payment c. any endorsments d. any attachments |
b |
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in most states the policy becomes incontestible after ___ years |
2 |
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Normall, written proofs of loss must be furnished within how many days after the loss? 15,45,60,90 |
90 |
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The insurer may generally require an autopsy at its own expense unless:
a. deceased requests in writing b. deceased reletive requests c. deceased relatives have proven religious objections d. state has applicable law that forbids autopsy
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d |
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when betty purhcased her insuranc epolicy, her age was recorded as 32 when she was actually 34. assuming he rpolicy includes the misstatement of age of provision and the insurance co discovers this 4 years later, bett's policy:
a. will be cancled for misinterpritation b. will be unchanged because incontestable period has expired c. limits lowered d. limits raised |
c |
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the optional provision that deal with multiple insurance policies of the same type on a singl einsured deal with the problem of a. underinsuarnce b. overinsurance c. innapropreate insurance d incorrect insurance |
b |
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a pro rata return is one in which th einsurer returns:
a. all of the unearned premium b. some of the unearned premium c. both earned and unearned premium d. neither earned nor unearned premium |
A |
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the grace period varies according to:
a. premium payment frequency a. premium pament amount c. method of prem pmt d. type of polciy |
a |
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Mike allows his policy to lapse, then applies for reinstatement using the company's required application. The fcompany does not inform mike teither that the polciy has bene accepted or that the policy is being rejceted. At what point can mike consider the policy reinstated?
a. not until the insurer notifies him that it has bene reinstated b. as soon as the app has bene submitted c. after 45 days d. after 90 days |
d |
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a reinstated policy will cover a. sicness immediately anadccidents after 10 days b. both sickness n accidents after 10 days c. accidents after 10 days and sickness 30 d. accidents immedatly, sick 10 days |
d |
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if an insured is disabled for at lesat two years, the insurer may requrie proof of continuance of disabiliyt every
mont, 2, 6, 12 |
6 months |
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because the insurer needs time to respont to a claim, the law provides the insurer with a window during which the insured cannot sue to recover under a calaim... window lasts for:
30, 60, 90 120 days |
60 |
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max time during which suit can be filed is how many years after written proof of loss is furnashed?
1, 2, 3, 4 |
3 |
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a revocable beneficary
a. has the right to refurse assignment of the policy b. may stop the policyowner from disposing of th epolicy c. may be changed without the beneficary's consent d. is assigned for life |
c |
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wof is not requried provision under uniform provisions model act?
a. grace period b. change of occupation c. time of payment of claims d. proof of loss |
b |
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wof is an optional provision under th euniform provisions model act?
a. cancelation b. physical exam/autopsy c. legal actions d. reinstatement |
a |
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job change to less money. becomes disabled 3 years later, benefit is more than 3 years salary. if policy contains average earnings clause, joes beneefit will be
a. same as in policy b. lesser of joes monthly earnings at time of disbality or avg monthly earnings of period 2 years immediately preceeding his disablity c. greater of above d. c + insuere returns some of excess premiums |
D |
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cancles HI policy, insurer will isue
a. pro rata refund of all the unearned premium b. pro rata refund of most of unearned premium c. short rate refnd of all the unearnd prem d. short rate refund of most of th eunearned prem |
d |
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hit by car against light. if policy contians illegal occupation provision the insure
a. not lieable for calim becaus ejoel was engagned in illegal activity at time of accident b. not liable for claim because joes illegal activity was the direct cause of the accident c. will pay the calim because offense isn't felony or regular occupation d. may or may not pay, depending on his job |
c |
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carmen gets hera health insurnace plicy on may one, on 5/3 she decisdes hse doesnt want it and returns. May 6 hit by car. co will
a. pay any resulting claim because she was isnjured w/in 10 day free look pd b. pay any resulting claim only fi the premium hasn't bene returned c. pay any resultying claim minus the amount of the returend premium d. only return any premium carmen has paid an not resulting claim |
D |
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consideration for ahealth polciy includeds
a. premium only b. stmets mad ein teh application only c. stmts made int he applicatn and insuring clause d. stmts made in the aplication and the premium |
d |
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wants to take aout an optionally rewnewable health policy with an annual premium due on june 14. the insurer decides it nlonger wants to insrue the people with first nams longer htan five letters.
a. not allowd no good reason b. not allowed unless condition is specified in policy c. allowed, but nto till 6/14 next year d. cancel policy whenever it wants to |
c |
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guaranteed but not renewable. wof may the insurer not do
a. refuse to renew policy if njo premium paid b. increase the premiums on all members of class c. increase premiums on policy only d. refuse to renew the policy when ceecee reaches specified age |
c |
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noncanceble polcy, wof may insurer do?
a. cancle if geopre fials to pay prem b. increase prems on all memebrs of geroges class c. increase premiums on georges policy only d. cancel plicy if insurer chooses no longer to do busness in geroge's state |
a |
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wof true?
a. an exclusion is ap rovison that leiminates cogn for a specified condition; ar eduction is a provision that decreases benefists as a result of specified condidtion b. reduction is a provion that eliminates covg for specified condition; an ecxclusion is a provison that decreases bens as result of specified condition c. a reduction is a provision that liminates covg for a specified conditon; an dexception is a prevision that decreases benefits as a re sult o fspecified condition d. reduction is antoher term for exception |
a |
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Period of time at the staart of the policy when disability benefits for sickness are not paid |
Probation |
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totally disabled and unable to perform the duties of th ecurrent job |
Own occupation |
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unable to perform some but not all of the duties of your job and beneftis equal 50% of total disability benefits for up to six months |
partial disability |
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a waiting period after a disabilyt occurs before pmts begin |
elimination |
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Unable to perform some but not all of the duties of a job and benefitsa re proprtionate to loss of income and payable for the full poloycy term |
resiudal disabilyt |
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totally disabled and unabel to perform the duties of any job for which you are suited by education, trainign, or work experience |
any occupation |
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totally disabled based on loss of eyesignt or more than one limb |
presumptive disabiliity |
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provides income or lump sum benefits for vocational training |
Rehab benfit |
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provides for annual increases in the disabiliyt benefit to offset inflation |
cost of living |
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provides for policy premiums to be suspended after the insured has been disabled for a specific amount of time, such as 3 months |
waiver of premium |
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provides for the insured to be abel to purchase additional amounts of diabiliyt income periodically without proving insurablity |
future increase option |
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privides additional disabiliyt benefits equal to government benefits payable during any application or waiting period or if benefits are denied |
social insurance suppliment |
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provides addtl lump sum benefits to the insured or beneficiary if the insured loses limbs or dies as the direct result of an accidental injury |
accidnetal death and dismemberment |
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a disability policy that would pay a lump sum to a business to facilityate buy-sell agreement of a disabled owner is know as ____ |
disability buy out |
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a ___ ____ ____ policy is designed to indemnify a business for any routine expenses incurred in the event the owner of a businessbecomes disabled |
business overhead expense |
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To recieve benefits form a disabilty income policy for disablity due to sickness, the insured mus tbe
a. totally disabled b. partially c. either or d. deceased |
a |
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the benefit that pays the regular total disablity benefit during th elimination period when the insured is hospitalized is known as...
a. hospital confinement rider b. rehab benefit c. nondisabling injury rider d. offset rider |
a |
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social insurance supplements provide disability income a. before workers comp and ss begin pmts b. after workers comp and SS end pmts c. both d. neither |
C |
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Which definition of total disability i smore favorable to the insured?
a. own occupation b. any occupation c. they are the same interms of benefits to the insured d. there is no way to determine form the info provided |
a |
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occupationioal disabilty benefits are aften reduced by benefits received a. from SS only b. from workers comp only c. either SS or WC d. before the end of elimination pd only |
C |
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some policies have replaced the partial disabiility provision with
a. a reduced disablity provision b. a redundant disability provision c. a recurrent disability provision d. a residual disabilty provision |
D |
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Guy gets hurt helping friend move. Insurer declines covg, saying the inury was not accidental under th eterms of policy. Policy must include
a. accidental bodily injury definition of accidental b. an accidental means definition of accidnetal c. a confining definition of accidnetal d. a nonconfining definition of accidental |
B |
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wof stmts regarding the future increase option rider is not true?
a. rate of addtnl covg will be a thte insured's attained age at the time of the purchase b. the rider guarantees the ability to increase coverage to a predtermined limit regardless of change in the insured's income c. the rider generally limits the number of option dates on which th einsured may purchase addtitional coverage d. the rider usually limits the amount of additional converage availible at each option date |
B |
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Disabilty benefits will generally be paid for the lifetime of the insured if total disabliiyt due to sicknes sbegins at age ___ or earlier
45, 50, 55, 65 |
55 |
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wof stmts regarding SS disabilyt benefits is true?
a. for benefits to be paid, the disabilty must be permanent and expected to end in death b. for benefits to be paid, the disablity must prevent the individual from being able to perform any substantial gainful work existing in the national econemy c. most of ht epeople who apply for disablity under SS are able to get benefits d. SS privides a farly liberal defnintion of total disablity in order to keep individuals able to spend an support the national economy |
B |
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wof statements about accidental death and dismemberment coverage is not true?
a. a schedule listing varios dismemberments and the sums that will be paid for them will be listed in teh policy b. the sums payabel are generally expressed as per centages of the death benefit limit or captl sum c. if th eppolicy has a disablity income feature, the disablity income pmts continue even after the dismemberment sum is paid d. even if the insured is not disabled after an accident, if a loss of limb or sight occurs within 90 days of the date of the acciden, the sums in teh schedule will be paid |
C |
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wof orgs would be most likely to be eligible fo rbusiness overhead expense insureance a. law firm w/ 15 partners b. doc's office c. major multinational corp d. public library |
B |
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to protect the business owner, the elimination period for disablity buyout insurance normall is
a. 1-2 weeks b. 3-6 months c. 6 months- 1 yr d. 1-2 yeras |
D |
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An MEI policy that pays a certain amount per visit for non-surgical physician visits eithe rin their office or in a hospital is known as ___ ___ ___. |
Regualr Med Expense |
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An MEI policy tha tpays a certain amount from a schedule or on a usual, customary, and reasonable basis to cover the physician's charges (surgeon and anesthiologist) related to a surgical procedure is known as ____ _____ . |
Surgical expense |
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An MEI policy that pays a certain amount per day or reimburses charges related to room an dboard plus certain misc charges whenthe insured is admitted to a hospital i sknown as ___ ___. |
Hospital expense |
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Primary exclusion for medical expense insurance. WAPSOC. |
-War -Aviation -Preexisting -Self Inflicted -Occupational (when coverd by WC) -Cosmetic and Well Care (non-injury dental and vision care) |
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Many major medical plans limit the amount paid by th einsured to some dollar amount. Beyond this amount called a ___ ___ ___, the insure pays 100% of covered chanregs upto the policy max benefit |
stop loss limit |
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In a supplemental Major Medical policy, the deductible that occurs between basic policy beneftis and major medical benefits is called a ___ |
Corridor deductible |
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poloicy covers hospital exp by paying a specified, predterermined amount per day, as shown in a schedule in the poliyc. a. remibursment choise b. expenses-incurred basis c. indemnity basis d. capitation basis |
C |
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intensive care benefits under hospital plans are a. never included b. generally provided at the same level as the room and board max c. genrally prvided at some multiple of the room an dboard maximum d. generally provided without limit based on the need of the insured |
C |
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out of pocket limit is als known as a. deductible b. copayment c. stopp loss d. max benefit |
c |
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wof is least likely to be covered by ajor med policy a. outpatient srevices b. dental care c. perscription drugs d. blood and blood plasma |
B |
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wof is least likely to be covered by a major medical policy a. surgery performed on outpatient basis b. replacemnt of artiicial limb c. nursing home care for a month following released d. purchase of blood for tranfusion during op |
b |
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broken leg, 2k med exp. policy pays entire amount.
a. major medical policy b. hospital income p c. comprehensive major medical p d. p w/ first dollar coverage |
D |
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hospital room and board paid on:
a. indemnit basis b. remibursment basis c. either d. neither |
C |
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type of health insurance providing high maaximum coverage for medical care is a. basica med exp policy b. major med exp p c. comprehensive med exp p d. supplemental med exp p |
b |
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type of policy that has a major medical portion that provides benefits onc ethe basic policy limits are exhausted and a deductibel has bene paid is a. basic med exp policy b. major med expp p c. comprehensive med exp p d. supplemental med exp p |
d |
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the type of policy covering doc visits while the insured is in the hospital is a. basica med exp p b. major med exp p c. comprehensive med exp p d. suppliment m e p |
a |
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Maternity benefits must be prvided on the sma ebasis as nonmaternity benefits a. in all cases b. only if th einsurer chooses to do so c. if the policy covers an employee group of 15+ people d. if hte policy provides disablity income covereag |
c |
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no loss/no gain laws require
a. replacing health insurance policies to cover any conditions for which there are ongoing claims under existing covg b. replacing HI to remove preexisting condition exclusions from all policies replaced c. existing insurers to continue to cover ongoing claims after a policy has been replaced d. existing insures to remove preexisiting condition exclusion from all policies being replaced |
a |
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the dollar limit beyond which the insured no logner participates in pmt of exp is
a. deductible b. coinsurance c. stop loss limit d. max benefit |
C |
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dolalr limit beyond which the insurer no longer participates in pmt of expenses is..
a. the deductibel b. coinsurance c. stop loss limit d. max benefit |
D |
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the exp that must be incurred before major medical benefits begin to be paid is a. deductible b. coinsurance c. stopp loss limit d. max benefit |
A |
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deductibel that runs between the first dollar coverage of a basic polic and the comprehensive coverage of a supplimental policy is known as |
corridor deductible |
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wof would most likely be covered under a medical expense policy?
a. gertrude steps on arusty nail and requiares tetanus shot b. flu shot c. annual check up d. requres help getting dressed in morning |
a |
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wof Full coverage vs. non-routine. List Full
1. Restorative 2. oral surgery 3. Routine dental visits 4. endodontics 5. flouride treatments 6. Peridontics 7. teeth xrays 8. Pediatric dentistry 9. exams and diagnosis |
3,5,7,9 |
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policy that pays an indemnity directly to the insured for each day the insured is admitted to a hospital, regardless of any other coverage the insured may have
a. dread disease isnurance b. travel accidnet insurance c. hospital indemnity insurance |
c |
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A policy that pay swhen expenses are incurred related to a specified illness, such as cancer or heart disease
a. dread disease Insurance b. travel accident insuance c. hospital indemnity insurance |
A |
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Credit health insurance covers a debtor, with the creditor receiving the benefits to pay off a debit if th edebtor is unable to pay the debt due to disability or death
T/F |
T |
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The most common type of credit health insurance is an individual policy requireng debtors to be individually u/w
T/F |
F |
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Credit health insurance may be written without notice to the debtor if th ecreditor is paying the premiums
T/F |
F |
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Schedueld benefits are generally a. lower than reasonable and customary allowances b. higher than c. same d. paid in additional to reasonable and customary allowances |
A |
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wof is not a commmon exclusion or limitation of dental policies?
a. benefits are genearally not payable for dental work that is not necessary for sound dental health b. teeth that are knocked out in an accident will generally not be replaced under a dental policy c. oral hygiene instructions and plaque control prongrams ar eoften limited or excluded d. prosthetic appliances generally may not be replaced for 5 years after benefit is paid |
b |
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prepaid dental plans offer servicies based on a. capitulation b. captive member selection c. concentration d. capitiation |
d |
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San Lan has a hospital income policy that will pay 1500 per month for up to 12 months. there is n oelimination period. If San Lan is hoptialized to whom will the insureer make payments?
a. hospital b. san lan c. the doc d. the beneficiary |
b |
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San Lan has a hospital income policy that will pay 1500 per month for up to 12 months. There is no elimination period. If Sin Lan is hopitalized for 10 days, how much wil lthe policy pay 50, 500, 1000, 1500 |
b |
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wof drugs may be excluded from a prescription drug policy?
a. ginseng b. fertility drugs c. rogain d. all |
d |
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a special type of policy tends to cover a. more areas than basic medical expense b. a broad number of situations as described in the policy itself c. a limtied number of situations as described in the policy itself d. whatever th einsured wants to be covered |
c |
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wof is not a common way dental insurance programs work to minimize adverse selection
a. increasing th emaximum annual benefit to encourage the insured to maintain dental health for the long term b. lowering the coinsurance percentage for optional expenses c. basing the benefit on the least costly treatment option d. graduation the coinsurance percetnage to increase each plan year |
a |
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main diff between preapaid dental plan and comprehensive dental plan?
a. comprehensive pay on the basis of reasonable and customary charges, whereas prepaid dental plans pay on a capitiation basis b. comprehensive dental plans pay on a capitiation basis, whereas prepaid dental plans pay based on reasonable and customary charges c. comprehensive cover routine services, wheras prepaid do not d. comprehensive do not cover routine that are covered by prepaid |
a |
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a prepaid dental plan that wants to restrict an enrollee's ability to receive services fro ma calss of providers a. is out of luck because such limitations are prohibited by law b. must request permisison for the isnsurance commissioner for the limitations c. must request permission from teh federal department fo insurance for the limitations d. must describe the limitations in the evidence of coverage and in all soliciatation documents |
d |
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dread disease policies a. are purchased to cover a variety of conditions that fall under the category of dread diseases b. cover any disease defined by the ADA s a dred deisease c. vover specific deseases as named in the policy such as hear or cancer d. are a good replacement for general healht insurance |
c |
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perscription drug policies generally exclude a. any narcotic substance b. any drugs no covered by other programs c. experimental drugs d. drugs for ongoing medical conditions |
c |
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the creditor must notify the debtor that she may be covered by the group insurance plan... a. only if th edebtor is to be garged the full premium for the insurance b. if the debtor is to be charged more than half the premium amount c. even if th ecreditor pays the full cost of the coverage d. only if thecreditor chooses to make the disclosure |
c |
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Conversion is permitted with evidence of insurability within two years of leaving employment if already under the care of a physician t/f |
F |
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the insured typically has ___ day sot convert to indvidual from group |
31 |
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A converted plan is typically issued with reduced or limited benefits |
T |
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Typically an individual plan has higher premium sthan group, but the coverage is usually better |
F |
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Employee Retirement and Income Security Act (ERISA)
what and when |
1974- Establishes stringesnt reporting and disclosure requirements for establishing and maintaining group health insurance and qulaified employer retirment plans |
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Tax Equity and fiscal Responsibility Act (TEFRA) |
1983- Prevents employers from discriminating in benfit plans in favor of key employees and make Medicare a secondary payor to group insurance for working employees even above age 65 |
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Consolidated Omnibus Budget Reconciliation Act (COBRA) |
1985 Requires employers with twenty or more employees to provide continuation of healh benefits for employees and their families when they leave the plan |
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Omnibus Budget Reconciliation Act (OBRA) |
1989 Extends COBRA benefits for disabled employees from 18 to 29 months and provides spouses and dependent children up to 36 months of beenfits if they lose COBRA benefits |
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Health Insurance Portability and Accountability Act (HIPAA) |
1997 Ensures portability of group health coverage and includes various benefits affecting small employers, the self-employed, pregnant women, and the mentally ill |
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WOF Individual opposed to group:
1. anyone may apply for coverage 2. There is one master contract 3. Covers both occupational and non-occupational accidents and sickness 4. each person has a policy 5. organization must preceed insurance |
I= 1, 3, 4 |
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aof dependants execpet:
a. adopted kids b. parents c. 25 y.o who became physically disabled at 24 d. 21 y.o i college full time |
c |
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carla enrolls in group insurance when she is eligible under her employer's plan. Because of an administrative error, her enrollment form is never sent to the compay. When sh elater has a claim, the insurer will
a. deny cuz no record b. force emplooyer to pay because it was employers error c. pay only if insurer is proven to have made an error d. accept the enrollment form and all ofthe past due premium and pay the claim |
d |
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which federal law requires employers with more than 20 employees to include in thei rgroup insurance plan a contrinuation of benefits provision for all eligible employees?
COBRA OBRA ERISA TEFRA |
COBRA |
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Which federal law is intended to prevent group term life plans from discriminating in favor fo key employees
COBRA OBRA ERISA TEFRA |
TEFRA |
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Which fed alw extends the minimum continuation of coverage period from 18 to 29 months for qualified beneficiaries disabled at the time of termination or reduction in hours?
COBRA OBRA ERISA TEFRA |
OBRA |
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Which fed law is intended to accomplish pension equity but also protects group insurance plan participants
COBRA OBRA ERISA TEFRA |
ERISA |
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Wof is not part of HIPAA?
a. employers must make full health care covg availible immediately to new hired employees who were previously covered for at least 18 months. b. new mothers and their babies mus tbe allowed to stay in the hospital for at least two days after reugalr delivery c. small employers may not be denied group health insurance covg because one or more employees is in poor health d. annual limits and lifetime speding limits may be applied to mental health coverage |
D |
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wof is considered a d/q event under COBRA
a. the employer ceases to maintain any group health plan b. the employee is no longer eligible for the group health plan becasue of a change in the covered classes c. the eomployee voluntarily leaves employment with the employer d. the employee's employment is terminated by the employer |
A |
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under OBRA, and employer may terminate COBRA coverage because of covg under another health plan
a. as soon as the covg i sin forse b. as long as the other health plan does not limit benefits for the insured's preexissting condititons c. as long as the hother health plan limits benefits for the insure's preexisting conditions d. only if the premiums for the new plan are paid entierely by the insured's new employer |
B |
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the age discrimniation in employment act applies to employees ___ or older |
40 |
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the Americans with Disabilities Act:
a. does not apply to aquired diseases such as AIDS b. permits exclusion of benefits for individual distinct groups of afflictions, such as cancer, muscular dystrophy, or kidney disease c. applies to all employers with twenty five or more mployees d. requres that employees with disabilities be given equal access to whatever health insurance is provided to other employees |
D |
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An alternative to traditional Medicare, Medicare advantage plans emphesize preventative care
part a, b c, d, medicare suppliments |
C |
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That optional part o fmedicare designed to pay for doctors services, home health, and certain outpatient medical services and supplies
part a, b c d , medicar suppliments |
b |
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A program of 10 standardized commercial insurance plans designed to fill the gaps and pay certain costs associated with medicare
part a b c d, medicare suppliments |
medicare suppliments |
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A part of medicare designed to assist with the costs of prescription drugs
Part A B C D medicare suppliments |
D |
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A part of medicare that pays for inpatitent hospital care, skilled nursing care, home health care, and hospice care
part a b c d; medicare suppliments |
A |
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T/F Medicaid is a welfare health program intended for the indigent |
T |
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T/F Eligibility for medicaid is set by federal statute |
F |
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T/F Medicaid covers most health care costs, including those associated with medicare, if appropreate |
T |
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T/F Medicaid excludes custodial or nursing home care, like medicare |
F |
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SS disabilyt benefits are availible for workers who are _(1)_ disabled, who are considered _(2)_ under the rules of Ss, whose disability is expected to last at least _(3)_ months or end in _(4)_, after waiting a period of _(5)_ months. |
1. totally and permanently 2. fully insured 3. 12 4. death 5. 5 |
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wof individuals is least likely to be eligible for medicare?
a. 65 just registered for SS benefits b. not eligble for SS, but is willing to pay a fee for her insurance c. diganosed with end-stage liver disease d. receiving benefits from SS for 3 years |
C |
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Under part B, pay deductible each ___
year, month, week |
Year |
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docs and suppliers who agree to accept the amount Medicare will pay are said to have agreed to a. payment b. assignment c. assesment d. capitation |
B |
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aof outpaitient services are covered under part B except:
a. artificial limbs b. emergency room services c. most immunizations d. physical therapy |
C |
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wof outpatient servicies is excluded from part B covg:
a. casts and splints b. lab tests billed by hospitals c medically necesary ambulace servaces d. hearing exams |
D |
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Michelle, 65, is starting to receive SS bens. To recieve part A she needs to
a. fill out an enrollment at local SS office b. monthly prem c. proove eligibility d. do nothing |
D |
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Does medicare pay all medical costs for its beneficiaries? |
no |
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Some kind of supplement to Medicare is needed by almost everyone covered by medicare. wof individuals woudl not need medicare suppliment insurance a. medical conditions under control at the moment b. income low enoguh to qualify for help from Medicade c. Net worth high enough to cover any medical bills that might incur d. high blood pressure that is controlld w/ medication |
B |
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Medicare select policies offer ____ coverage, compared with standard medigap policies
a. same b. more extensive c. less extensive d. unlimited |
A |
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Which type of policy requires use of approved doctors and hospitals to recieve beneftis? a. medicare select b. standard medigap policies c. both d. neither |
A |
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Medicare supplement policies are also knon as
a. medicare policies b. medigap policies c. medicaid policies d. medichoce policies |
B |
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aof statmetns about medigap insurance are correct except:
a. medigap policies are availible thru medicare b. medigap policies are sold by private insurance companies c. medigap policies were standardized by the NAIC d. medigap plan A covers basic benefits |
a
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wof benefits are nto required in any medicare supplement policy? a. skilled nursing care benefit that covers the part A copays for the 21st thru the 100th day of skilled nursing facility care b. part A copays for the 61st thru the 90th day of hospitalization c. part B copays on Medicare-approved charges for physician's and medical services d. all charges for 365 days of hospitalization after all part A inpatient hospital and lifetime reserve days are used up |
A |
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wof indivudal sis not likly to be eligble for medicaid a. single mom who relies on aid to families with dependent children to help feed her family b. unable to work since becoming blind 2 years ago c. nto able to work since losing both legs d. over 65, workign as a manager of retail outlet |
D |
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fully insured and disability insured are defined by a. state legislatures b. SS regulations c. individual insurers d. state departments of insurance |
B |
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under SS benefits, disabled workers receive a benefit equal to a. their earnings at the time of the disability b. 66% of their earnings at the time of the disablility c. their preffered insurance amount d. their primary insurance amount |
D |
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medicare is administered by a. the SS admin b. individual state govt's c. the centers for medicare and medicaid services (CMS) d. the health care focus association |
C |
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medicare part A covers all of the following excetp:
a. charges for private room b. skilled nurcing facilyt care c. home health care d. hospice care |
a |
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medicare will pay the entire cost for skilled mursing facility for the first
0, 20, 80, 100 days |
20 |
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Medicare part a provides covg for aof kinds of care except
a. private duty nursing b. skilled nursing facility care c. home health care d. hospice care |
a |
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meidcaer part b provides covg for aof kinds of care excpet a. skilled nurisng facility care not covered by part A b. doctors servicies c. home health care not covered by part A d. outpaitent medical services and suplies |
a |
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wof medicare supplement plans covers the part a and part b dedeuctibe
plan B, C, D, E |
Plan C |
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wof medicare upplement plans covers the part B excess at 80%
E, F G, H |
Plan G |
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wof stmts about medicare supplement plans is not true?
a. benefits must automatically change to coincide with changes in medicare deductibles and copays b. losses resulting from sickness may not be treated differently than losses resulitng form accidents c. the definition of accident may employ an accidnetal means test d. policies mut be at elast guaranteed renewable |
C |
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to be compensable as interpreted in workers comp law, an injury must meet aof criteria except:
a. accidnetal b. arise out of the individuals employment c. must arrise in the course of the indivuals employment d must be unforseeable |
d |
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juanita is employed in Cali. She takes a business trip to Colorado to deminstrate some technieuqs to workers in another facility and is injured in process. Her WC benefits will be paid according to the laws of
a. ca b. co c. whoever gives more d. whover gives less |
a |
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Medicare provides skilled nursing care incident to a period of hospitalization for up to 100 days per beenfit period
T/F |
t |
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Medicaid provides LTC benefits for all retired workers over 65
t/f |
f |
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Consumers are now required to purchase TTC coverage
t/f |
F |
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One-half of all medicaid spending goes to people who consumed all their resources and became impoverished whiel in a nursing home
t/f |
T |
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Nursing home care is genearlly covered by a. medicare b. medicare supplements c. LT care policies d. all |
C |
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wof woudl be least likely to be a good candidate for an LTC policy? a. las practice has allowed to fund a genearous retirement fund fo rhim and his wife b. single mom whose financial sturgles raising her kid shave left her with few assets and no independent retiremnt savings c. 25 years of civil service have provided a generous retirement, but who worries about the legacy she wil leave her children d. Darrell, whos inherited estate has provided him wiht over 6 mil in net worth |
b |
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An individual age 65+ has what % chance of being confiened to a nurisng home?
25, 50, 75, 90 |
A |
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wof individuals is most likely to be rated substandard risk under LTC policy a. lives alone, no trouble taking care of self, diagnosed with unoperable brain aneurysm that will kill him instantly if it bursts. b. on meds to bring down his blood pressure, but who gets around and takes care of self easilly c. diabetis, but under control d. garrison, who has been diagnosed with early-stage altzheimers |
D |
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wof is the type of care most peopel will require at some peopnt duing their later years
a. inpatient hospital care b. skilled nursing care c. custodial or residential care d. intermediate care |
C |
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Virtually all of the current LTC policies are guaranteed rewnewable. This means the insurer cannot cancle the policy a. but does reserve right to increase policy premiums on specifiedclasses of policies b. but does reserve the right to increase policy premiums on individual policies c. or increase policy premiums on specified classes of policies d. or increase policy premiums on indiviudual policies |
A |
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When waiver of premium applies a. the premium is waived immediately upon disability b. the premium payment is suspended permanently once it is invoked c. the premium payment genearlly resumes when care ceases d. the premium payment is waived only if disability is considered permanaent and total |
C |
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Typically, the expenses incurred in a hospice will be a. surgical, room, and board b. room, board, pt c. surgical, pt d. room, board, pain meds |
D |
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Prems and bens taxed?
Individual MEI, MM, and most other policies |
PT, BnT |
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prems and bens taxed? sole proprietor and partnership MEI, MM an dmost health |
Pnt, Bnt |
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bens and prems taxed? group health insurance (paid by employer) |
PnT, BnT |
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Individual DI or indiviudal share of group DI prems and bens taxed? |
PT, BnT |
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prems and bens taxed? Group DI (paid by employer) |
PnT, BT |
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Business overhead exp (BOE) presm and bens taxed? |
PnT, BT |
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Wanda's company pays the entire premium for her group disablikty covg. If wanda became disabled, how much of her benefits from this covg would be subject to tax?
a. all b. none c. half d. depends |
A |
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The donugt co may deduct its premiums for businesss overhead expense insurance a. only if it is a corp b. only if it iis a pratnership or corp c. corp, partnership, sole p d. prems nto deductible |
C |
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Prems are deductibel for wof?
a. disability policy to fund a buy-sell agreement b. key employee disability policy c. both and and b d. neither |
d |
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SS disability income and medical benefits are financed through a. voluntary contributions b. mandatory payroll taxes c. state govt d. ERISA |
B |
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The taxes to finance SS benefits are paid a. soley by employees b. soley by employers c. equally by employees and employers d. the fed govt |
C |
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Medicare part A hospital insurance is primarilly funded by a. general tax rev b. prems from beneficaries c. state govt taxes d. SS payroll taxes |
D |
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SS taxes are paid by employees iwth a. pretax dollars b. tax-deducitble dollars c. after-tax dollars d. tax-deferred dollars |
C |
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prems for idividually owned health policies may be deductible if the taxpayers medical expenses exceed a. 5% of adjusted gross income during taxible year b. 5% of their adjusted net income during the taxable year c. 7.5% of their adjusted gross income during the taxable year d. 7.5% of their adjusted net income durin ght etaxable year |
C |
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The premiums paid by a company for group health for its employees are a. not tax deductible to either the company or th ebusiness b. tax deductibel by the company and not considered taxible income to the employees c. ta deductibel by the company and considered taxable income to the employees d. tax deductibel to the employees and the company |
B |
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Qualified group lt care covg is a. deductibel by both company and employee b. not deductibel by eaither c. deducitble by company only d. deductibel by employee only |
C |
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Indivdual disability insurance prems are a. deductibel to insured, and benefits are frecievd tax free b. not deductible to the insured, bu tthe benefits are received tax free c. deductibel to the insured, but the beenefits are taxed d. not deductible to the insured, and the bensefts taxed |
B |
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an individual who is considered chronically ill must be recertified as such a. every month b. every 6 months c. annually d. every 2 years |
C |
