Social Health

Front 1

Which of the following statements pertaining to Medicare is CORRECT?

* A) Bob is covered under Medicare Part B. He submitted a total of $1,100 of approved medical charges to Medicare after paying the required deductible. Of that total, Bob must pay $880.
* B) Medicare Part A is automatically provided when a qualified individual applies for Social Security benefits.
* C) For the first 90 days of hospitalization, Medicare Part A pays 100% of all covered services, except for an initial deductible.
* D) Each individual covered by Medicare Part A is allowed one 90-day benefit period per year.

Back 1

b

Medicare Part A is available when an individual turns 65 and is automatically provided when he or she applies for Social Security benefits. Medicare Part B pays 80% of medical expenses after the insured pays the deductible.

Front 2

If a disabled Medicare enrollee is also covered by an employer-provided health plan as a family member:

* A) the employer's health plan will always be considered the secondary payor because the plan participant is a family member, not an employee.
* B) Medicare will only provide disability income benefits since the plan participant is covered by an employer-provided health plan.
* C) Medicare will always be considered the primary payor.
* D) the employer's health plan will be the primary payor if it covers 100 or more employees.

Back 2

D

If a disabled Medicare enrollee is also covered by an employer-provided health plan as an employee or family member, the employer's plan will be considered the primary payor, but only if it covers 100 or more employees.

Front 3

A Medicare Select policy is a Medicare supplement policy or certificate that contains:

* A) provisions limiting benefits because of the applicant's current health status.
* B) restricted network provisions.
* C) unlimited access to health service providers.
* D) provisions limiting benefits for preexisting conditions.

Back 3

B

A Medicare Select policy contains restricted network provisions (i.e., the payment of benefits is conditioned on the use of network providers who have entered into written agreements with the insurer to provide benefits under a Medicare Select policy).

Front 4

Medicare Plans K and L are characterized by which of the following features?

* A) No annual deductible.
* B) No annual limit on annual out-of-pocket expenditures.
* C) Higher coinsurance contributions.
* D) Lower co-payments.

Back 4

C

Medicare supplement Plans K and L require a higher co-payment and coinsurance contribution from Medicare beneficiaries. They also have a limit on annual out-of-pocket expenditures incurred by the policyholders. However, once the out-of-pocket limit on annual expenditures is reached, the policy covers 100% of all cost-sharing under Medicare Parts A and B for the balance of the calendar year.

Front 5

All of the following statements about workers' compensation are true EXCEPT:

* A) Workers' compensation laws are designed to return injured persons to work.
* B) Benefits include medical care costs and disability income.
* C) All states have workers' compensation laws.
* D) A worker receives benefits only if the work-related injury was not his fault.

Back 5

D

All states have workers' compensation laws that are designed to help injured workers recover and return to work. They are based on the principle that the employer should compensate the injured employee for work-related injuries, regardless of fault.

Front 6

Which of these statements regarding Medicare is CORRECT?

* A) Medicare recipients are billed for their Medicare Part A premiums on a semiannual basis.
* B) Under Medicare Part B, payments for physicians' services are unlimited.
* C) Medicare Part A Hospital Insurance (HI) carries no deductible.
* D) Medicare Part B Supplement Medicare Insurance (SMI) is voluntary.

Back 6

D

Medicare coverage has two distinct parts: Hospital Insurance (Part A) and Medical Insurance (Part B). Medicare Part A is automatically available to persons who have turned 65 and have applied for Social Security benefits. Part B is voluntary and may be elected or rejected as the recipient wishes.

Front 7

Tom is covered under Medicare Part A. He spends 1 week in the hospital for some minor surgery and returns home on July 10. It was his first hospital stay in years. He pays his deductible and Medicare pays the balance. He is then admitted to the hospital again on November 1 of that same year, when he returns for more surgery. Which of the following statements is CORRECT?

* A) It will be considered the start of a new benefit period.
* B) He need not pay the Part A deductible, but must make a daily copayment.
* C) He will not have to pay the Part A deductible again.
* D) Tom will have to pay the Part A deductible again only if the second surgery is unrelated to the first surgery.

Back 7

A

The second hospitalization is part of a new benefit period, since it begins more than 60 days after the first hospitalization started. The new benefit period will require payment of the deductible again, but another hospitalization period of 60 days with 100% coverage of benefits is available.

Front 8

Which of the following statements about Medicare supplement insurance choices available for retirees under an employer group insurance plan is NOT correct?

* A) Plans A through J are essentially identical, with minor increases at each level.
* B) Participants have a 6-month open enrollment period.
* C) Participants must be enrolled in Medicare Part A.
* D) Participants cannot be denied coverage because of health problems.

Back 8

A

Plans A through L offer increasingly comprehensive coverage, at additional premiums.

Front 9

For how many days of care in a skilled nursing facility will Medicare pay benefits?

* A) 75 days.
* B) 100 days.
* C) 20 days.
* D) 60 days.

Back 9

B

Medicare Part A covers the cost of care in a skilled nursing facility as long as the patient was first hospitalized for three consecutive days. Treatment in a skilled nursing facility is covered in full for the first 20 days. From the 21st to the 100th day, the patient must pay the daily copayment. There are no Medicare benefits provided for treatment in a skilled nursing facility beyond 100 days.

Front 10

Under Medicare Part A, the participant must pay his or her deductible:

* A) monthly.
* B) annually.
* C) twice per benefit period.
* D) once per benefit period.

Back 10

D

For Medicare Part A, the participant must pay his or her deductible once per benefit period. A benefit period starts when a patient enters the hospital and ends when the patient has been out of the hospital for 60 consecutive days. Once 60 days have passed, any new hospital admission is considered to be the start of a new benefit period. Thus, if a patient reenters a hospital after a benefit period ends, a new deductible is required and the 90-day hospital coverage period is renewed.

Front 11

The core policy (Plan A) developed by NAIC as a standard Medicare supplement policy includes all of the following EXCEPT:

* A) coverage for the Medicare Part A deductible.
* B) coverage for the 20% Part B coinsurance amounts for Medicare-approved services.
* C) coverage for the first 3 pints of blood each year.
* D) coverage for the Part A coinsurance amounts.

Back 11

A

The Medicare Plan A supplement policy does not provide coverage for the Medicare Part A deductible. All the other answer choices are included in the core benefits that all medicare supplement policies must provide, including Medicare Plan A supplement policies.

Front 12

Those who choose not to enroll in Part B when first applying for Medicare may do so:

* A) at any time after enrolling in Part A.
* B) on the anniversary of his Part A enrollment date.
* C) between July and September of each year.
* D) during an annual open enrollment period.

Back 12

D

Applicants can choose to enroll in Part B of Medicare during the open enrollment period each year from January 1 through March 31. Coverage then begins the following July 1.

Front 13

Which of the following is NOT available to Medicare beneficiaries through the Medicare Advantage Program?

* A) PPOs.
* B) Medicaid.
* C) HMOs.
* D) PSOs.

Back 13

B

The Medicare Advantage Program gives Medicare beneficiaries a number of alternatives from which to obtain Medicare-covered services. Medicare participants are also able to take advantage of tax-free medical savings accounts (MSAs) for routine medical bills and a government-funded high deductible MSA health plan (MSA plan) for catastrophic expenses. The program also offers a combination of private fee-for-service health plans and self-funding, and private contracts with physicians for particular services. Medicaid offers assistance with medical costs to low-income individuals.

Front 14

A Medicare supplement policy that contains restricted network provisions is known as a:

* A) Medicare SELECT policy.
* B) individual health policy.
* C) long-term care policy.
* D) HMO.

Back 14

A

A Medicare select policy or Medicare select certificate mean respectively a Medicare supplement policy or certificate that contains restricted network provisions.

Front 15

A disabled 65-year-old employee of a company with 90 employees suffers a heart attack and, as a result, becomes totally disabled. Which of the following statements describes how his health benefits will be paid?

* A) His employer-sponsored health insurance pays full benefits. After that, Medicare pays the remainder.
* B) Because he is an active employee, his employer-sponsored health insurance is responsible for paying all benefits.
* C) Because he is over age 65, Medicare is responsible for paying all benefits.
* D) Medicare pays all or the majority of benefits. After that, his employer-sponsored health insurance may pay an additional benefit.

Back 15

D

The Medicare Secondary Rule (which requires the private insurer to first pay benefits) does not apply to groups of fewer than 100 persons. Therefore, it is likely that Medicare will pay benefits up to maximum eligibility. Thereafter, if the employee is covered under the group plan, that plan will then pay additional benefits.

Front 16

What is the MAXIMUM number of days of skilled nursing facility care for which Medicare will pay benefits?

* A) 100 days.
* B) 60 days.
* C) 75 days.
* D) 25 days.

Back 16

A

Part A covers the costs of care in a skilled nursing facility as long as the patient was first hospitalized for three consecutive days. Medicare will cover treatment in a skilled nursing facility in full for the first 20 days. From the 21st to the 100th day, the patient must pay a daily copayment (up to $97 per day in 2000). There are no Medicare benefits provided for treatment in a skilled nursing facility beyond 100 days.

Front 17

A main goal of Medicare Part C is to:

* A) encourage Medicare enrollees to purchase Medicare supplement insurance.
* B) eliminate the traditional fee-for-service Medicare program.
* C) encourage individuals aged 65 and over to enroll in the Medicare program.
* D) encourage Medicare beneficiaries to join private health plans as an alternative to the traditional fee-for-service Medicare program.

Back 17

D

A major goal of Medicare Part C is to encourage beneficiaries to join private health plans as an alternative to the traditional fee-for-service Medicare program. The intent is to reduce the financial strain on Medicare funds and to provide Medicare beneficiaries with a variety of new health options.

Front 18

Medicare Part B covers which of the following?

* A) Eyeglasses.
* B) Foot care.
* C) Hearing aids.
* D) X-rays.

Back 18

D

Medicare Part B covers physician services, diagnostic tests (such as x-rays), physical and occupational therapy, medical supplies, mammograms, and flu shots. It does not cover routine physical exams, eyeglasses, dental care, hearing aids, most prescription drugs, orthopedic shoes, or routine foot care.

Front 19

Tom is covered under Medicare Part A. He spends 1 week in the hospital for some minor surgery and returns home on July 10. It was his first hospital stay in years. Which of the following statements is CORRECT regarding his Medicare coverage?

* A) After Tom pays the deductible, Medicare will pay 80% of all covered charges.
* B) After Tom pays the deductible, Medicare will pay 100% of all covered charges.
* C) Medicare will pay benefits, but Tom must make a daily copayment.
* D) Medicare will not cover Tom's hospital expenses because he was not hospitalized for 10 consecutive days.

Back 19

B

Medicare pays 100% of covered services for the first 60 days of hospitalization after the deductible is paid.

Front 20

Lynn is insured under Medicare Part A and enters the hospital for surgery. Assuming that Lynn has not yet tapped into her lifetime reserve, what is the maximum number of days that Medicare will pay for her hospital bills?

* A) 120 days.
* B) 60 days.
* C) 90 days.
* D) 150 days.

Back 20

D

After an initial deductible is met, Medicare pays for all covered hospital charges for the first 60 days of hospitalization. The next 30 days are also covered, but the patient will be required to contribute a certain daily amount. If, after these first 90 days the patient is still hospitalized, he can tap into a lifetime reserve of an additional 60 days, paying a higher level of daily co-payments. Consequently, a patient who has not yet tapped into the lifetime reserve days could have up to 150 days of Medicare coverage for 1 hospital stay.

Front 21

A disabled worker's unmarried dependent child who is younger than 18 years is eligible for monthly benefits equal to how much of the worker's primary insurance amount (PIA)?

* A) 100%.
* B) 25%.
* C) 75%.
* D) 50%.

Back 21

D

A disabled worker's unmarried dependent child who is younger than 18 years, or who is disabled before reaching age 22, is eligible for monthly benefits equal to 50% of the worker's PIA.

Front 22

Skilled nursing care differs from intermediate care in which of the following ways?

* A) Skilled nursing care must be available 24 hours a day, whereas intermediate care is daily, but not 24-hour, care.
* B) Skilled nursing care is typically given in a nursing home, whereas intermediate care is usually given at home.
* C) Skilled nursing care must be performed by skilled medical professionals, whereas intermediate care does not require medical training.
* D) Skilled nursing care encompasses rehabilitation, whereas intermediate care is for meeting daily personal needs, such as bathing and dressing.

Back 22

A

Unlike intermediate care, skilled nursing care is continuous, around-the-clock care provided by licensed medical professionals under the direct supervision of a physician. It is usually administered in nursing homes. Intermediate care is provided by registered nurses, licensed practical nurses, and nurse's aides under the supervision of a physician. Intermediate care is provided in nursing homes for stable medical conditions that require daily, but not 24-hour, supervision.

Front 23

Which of the following statements about Medicare Part D is CORRECT?

* A) It is available to anyone enrolled in Medicare Part A or B.
* B) Some plans offer basic drug coverage.
* C) It helps cover the costs of hospitalization.
* D) Benefits are available only through Medicare Advantage plans.

Back 23

A

Medicare Part D helps cover the cost of prescription drugs. It is available to anyone enrolled in Medicare Part A or B. Benefits are available through private prescription drugs plans or Medicare Advantage plans. All plans must offer basic drug coverage.

Front 24

What benefits does Medicare provide for treatment in a skilled nursing care facility after 100 days?

* A) None.
* B) Coverage for physical and occupational therapy only.
* C) Reduced coverage with a higher copayment from the insured.
* D) Coverage for diagnostic services and medical supplies only.

Back 24

A

Medicare does not pay benefits for treatment in a skilled nursing care facility beyond 100 days.

Front 25

Under Medicare Part B, the participant must pay:

* A) 80% of covered charges above the deductible.
* B) 20% of covered charges above the deductible.
* C) a per benefit deductible.
* D) a yearly premium.

Back 25

B

Part B participants are required to pay a monthly premium and are responsible for an annual deductible. After the deductible, Part B will pay 80% of covered expenses, subject to Medicare's standards for reasonable charges.

Front 26

Paul, age 66, works for American Accounting, Inc., a firm with 500 employees. He is covered by its health insurance plan. He is also covered by Medicare. Which of the following statements is CORRECT?

* A) American Accounting's plan is the primary payor, and Medicare is the secondary payor.
* B) Medicare is the primary payor, and American Accounting's plan is the secondary payor.
* C) Medicare will pay only the deductibles that are not covered by American Accounting's plan.
* D) Medicare is not required to provide coverage for Paul.

Back 26

A

Because Paul is over age 65, he is eligible for Medicare. He is also entitled to the same health insurance benefits that American Accounting offers to its younger employees. In this case, the employer-sponsored plan is considered the primary payor and Medicare is the secondary payor. This means that Medicare pays only those charges that the employer-sponsored plan does not cover.

Front 27

An individual who requires 24-hour-a-day supervision by skilled medical professionals in a nursing home receives what kind of care?

* A) custodial care.
* B) skilled nursing care.
* C) respite care.
* D) intermediate nursing care.

Back 27

B

Skilled nursing care is daily nursing care performed by, or under the supervision of, skilled medical professionals and is available 24 hours a day. It is typically administered in nursing homes.

Front 28

According to the National Association of Insurance Commissioners' standardized model Medicare supplement policy, insurers must offer coverage for all of the following core benefits EXCEPT:

* A) Medicare Part A-eligible hospital expenses not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period.
* B) the Medicare Part A deductible.
* C) the coinsurance amount of Medicare Part B eligible expenses, regardless of hospital confinement, subject to the Medicare Part B deductible.
* D) coverage under Medicare Parts A and B for the first 3 pints of blood or equivalent (unless replaced according to federal regulations).

Back 28

B

All Medicare supplement policies must provide certain core benefits, including coverage for Medicare Part A-eligible hospital expenses not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period, the coinsurance amount of Medicare Part B eligible expenses, and coverage under Medicare Parts A and B for the first 3 pints of blood. Although Plan A does not provide coverage for the Medicare Part A deductible, other Medicare supplement policies (Plans B through J) cover this deductible.

Front 29

In the standardized Medicare supplement policy, Plan A is characterized by:

* A) availability only to Medicare recipients younger than age 75.
* B) offering the widest coverage.
* C) duplicating Medicare benefits for maximum security.
* D) providing the least comprehensive coverage.

Back 29

D

In the 12 standardized Medicare supplement plans, Plan A provides the least coverage and is referred to as the core plan. Plan J has the most comprehensive coverage. Plans K and L provide basic benefits similar to plans A-J, but cost-sharing is at different levels.

Front 30

Marilyn is enrolled in Medicare Parts A and B. She lacks prescription drug coverage. Her insurance agent recommends that she purchase Medicare supplement Plan J as a comprehensive means of covering her prescription drug costs. What should Marilyn do?

A) Ignore the recommendation because Plan J is no longer available with prescription drug coverage.
B) Consider the purchase of Plans H or I as alternative means of obtaining this coverage.
C) Purchase Plan J, but with limited coverage for prescription drugs.
D) Consider the recommendation if she trusts her agent.

Back 30

A

Three of the standard Medicare supplement plans-H, I, and J-include coverage for prescription drugs. However, as of January 1, 2006, they cannot be sold with coverage for prescription drugs. Instead, Medicare beneficiaries who do not already have coverage for prescription drugs under Plans H, I, or J (bought before January 1, 2006) must obtain this coverage through Medicare Part D. A beneficiary who has Plan H, I, or J and enrolls in Part D will have the drug coverage eliminated from the Medicare supplement plan.

Front 31

After paying the monthly premium and annual deductible under Medicare Part D, the proportion of prescription drug costs that Medicare beneficiaries pay is:

* A) 10%.
* B) 20%.
* C) 25%.
* D) 15%.

Back 31

C

Under the standard benefit, Medicare beneficiaries pay a projected monthly premium of $21 and a $265 annual deductible. Then they pay 25% of the first $2,400 of prescription drug costs, and Medicare pays the other 75%. Coverage then stops completely. However, if the beneficiary's total drug costs are more than $5,451.25 after the beneficiary has spent another $3,850, coverage resumes and beneficiaries pay a co-payment of $2.15 for generic drugs and $5.35 for brand name drugs or 5% of total costs, whichever is higher. (These figures are for 2007 and are scheduled to increase each year.)

Front 32

Charles signs up for Medicare Part B on March 21 during the open enrollment period. His coverage will become effective:

* A) June 30.
* B) April 1.
* C) March 21.
* D) July 1.

Back 32

D

Medicare Part B coverage for those who sign on during the open enrollment period always becomes effective the following July 1.

Front 33

The Medicare Advantage Program offers all of the following to Medicare beneficiaries EXCEPT:

* A) provider-sponsored organizations (PSOs).
* B) Medicaid.
* C) health maintenance organizations (HMOs).
* D) preferred provider organizations (PPOs).

Back 33

B

The Medicare Advantage Program (Medicare Part C) gives Medicare beneficiaries a variety of alternatives from which to obtain Medicare-covered services. Medicare participants are also able to take advantage of tax-free health savings accounts (HSAs) for routine medical bills and a government-funded, high-deductible health plan (HSA plan) for catastrophic expenses. The program also offers a combination of private fee-for-service health plans, self-funding, and private contracts with doctors for particular services. Medicaid offers assistance with medical costs to low-income individuals.