Health 1

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Health 1 1. Stagmite purchases a major medical policy with a $100 annual deductible, 80/20 co-insurance and a stop loss of $5000. If Stagmite were to incur covered expenses of $10,100, how much would Stag be out of pocket? $5000 $5100 $2000 $2100 2. Which of the following are NOT eligible for Medicare coverage? People age 65 and older who are eligible for Social Security People age 65 and older not eligible for Social Security, but willing to pay a monthly premium People of any age who have been entitled to S.S. Disability benefits People with any life threatening condition 3. When benefits are paid to a policyowner covered under a Hospital Expense policy, the policy is considered to be which of the following? Service Limited Fixed-Rate plan Special Risk 4. All of the following statements concerning Social Security disability benefits are true except: The impairment must be expected to last at least 12 months. The waiting period is 5 months. The waiting period may be waived in certain circumstances. Benefits are retroactive to the time of disability. 5. Which of the following statements is true about Basic Hospital, Medical, and Surgical Expense Policies? They have high deductibles. The benefits provided are usually equal to the actual expenses incurred. They usually have a stated limit for specific expenses. Benefits are provided for loss of income. 6. HMO's are known for stressing state sponsored health plans in hospital care and services health care services for government employees preventive medicine and early treatment 7. All the following benefits from a major medical policy could be expected to be paid except: Dentists Optomitrists Chiropractors Naturopaths 8. Which of the following non-insurance entities are involved with self-insured plans? I. Third Party Administrator II. Administrative Services Organization III. Preferred Provider Organization IV. Health Maintenance Organization I & IV III & IV I & II II & III 9. Which of the following statements is true regarding Multiple Employer Trusts ? Multiple Employer Trusts require employers to have an employment-related common bond. The Multiple Employer Trust, not the employer, is the contract holder. Multiple Employer Welfare Arrangements are designed for those below a certain income level. An employer must subscribe to all the coverages of the Multiple Employer Trust. 10. Which of the following statements about deductible provisions in medical insurance policies is NOT correct? They help to eliminate small claims They provide that initial expenses up to a specified amount are to be paid by the insured They are most common in basic medical expense policies They help to hold down premium rates 11. Which of the following statements is usually true about a Medical Expense policy? It is available on a group basis only. It covers accidental injuries only. It pays benefits on a cost-incurred basis only. It covers hospital expenses only. 12. Phil M. Cick is to have surgery and his physician states that the surgery can be performed either as an out patient or as an in-patient. Phil's policy will pay: the out-patient surgery only the in-patient surgery only either in or out patient everything only after a pre-certification has been given for the needed surgery 13. Which of the following is/are true concerning Blue Cross/Blue Shield? 1. They are mutual companies. 2. They are stock companies. 3. They are non-profit. 4. They sell only family and group plans. 1 only 2 only 1 & 3 1, 3, & 4 14. Which of the following companies can sell health insurance? I. Mono-Line II. Home Service/Industrial III. Property/Casualty IV. Multi-Lines Company I II & III III & IV All the above 15. Health insurance may be written by all the following types of companies except: Life Casualty Surety Home Service 16. Grouping small businesses together to obtain group insurance as one large group is characteristic of which of the following? A Health Maintenance Organization (HMO) A Franchise Health plan A Multiple Employer Trust (MET) A Fictitious group 17. The type of health care provider that provides both the health care services and the health care coverage is a: Preferred Provider Organization Health Maintenance Organization Blue Cross/Blue Shield organization Traditional health insurance company 18. All of the following are types of deductible provisions associated with major medical policies except: corridor integrated stop loss flat 19. Which of the following is true about coinsurance? Coinsurance applies to the deductible as well as to claim payments. Premiums are higher for a policy that contains a coinsurance provision than for one that does not. It helps control overutilization of benefits. Insurance companies can change the coinsurance ratio after the policy has been issued. 20. In a Basic Surgical policy, which of the following pays per point? Relative Value Surgical Schedule Reasonable and Customary Surgical Point 21. A Comprehensive Medical Expense policy combines the benefits of what two types of plans? Hospital Expense and Surgical Expense Basic Medical and Major Medical Major Medical and Disability A.D.& D. and Major Medical 22. Which is not true concerning a Hospital Fixed-Rate plan? Claim costs are not affected by rising health care costs High benefits for relatively low premiums Simple underwriting and administration Benefits are paid directly to the hospital 23. All of the following are eligible for Medicare except: those 65 or older dependents of those 65 or older folks with a chronic kidney disorder folks receiving Social Security Disability benefits 24. The usual payment arrangement under a Preferred Provider Organization contract is: a fee for each service. a flat monthly amount for each subscriber. reimbursement to the individual subscriber. any of the above. 25. The basis for determining the benefits on a Basic Hospital Expense Plan is: daily room and board miscellaneous expense surgical expense relative value 26. Which of the following is the most common type of co-insurance in a major medical policy? 5 -10% 10 -15% 20 -25% 25 -30% 27. Another term used for Home Service insurers is: Franchise insurers Wholesale insurers Debit insurers Door to door insurers 28. The term FIRST DOLLAR often is used to describe benefits payable by which type of policy? A Hospital Indemnity policy A Disability Income policy A Business Overhead Expense policy A Major Medical policy 29. Which statement concerning HMO's is correct? Open panel HMO doctors are currently accepting new subscribers. Closed Panel HMO doctors have discontinued their association with the HMO. Open panel HMO doctors have their own patients as well as work with the HMO. I am tired, tired, tired of all this. 30. An applicant for insurance may pay the initial premium and receive a document from the agent indicating that if the policy is issued as requested coverage begins on the date of the documents. What is this document called? Executing agreements Conditional receipt Warranty Notice of inspection 31. The optional short term disability benefit that pays a lump sum for specified injuries is called the: hospital income benefit indemnity benefit supplement income benefit partial disability benefit 32. Which of the following is not correct concerning Health Maintenance Organizations? Members may be part of a group, individual, or family plan. They may be self-funded. They finance health care on a pre-payment basis. They mandate enrollment for groups of 25 or more. 33. Which of the following is usually not considered health insurance? Dental Insurance Medical Expense Disability Insurance Acc. Death & Dismemberment 34. Which of the following are NOT eligible for Medicare coverage? People age 65 and older eligible for Social Security People age 65 and older not eligible for Social Security, but willing to pay a monthly premium People of any age who have been entitled to S.S. Disability benefits People with any life threatening condition 35. A certain major medical policy states a maximum number of days for which convalescent care will be paid as well as a maximum number of X-rays that will be paid for under any one claim. These are examples of: First dollar coverage Inside limits Carryover provisions Stop-loss limits 36. Which medical expense plan is best suited for higher risks and greater loss? Major Medical Comprehensive Medical First-Dollar Dread Disease 37. Dread disease, travel accident, vision care, and hospital indemnity policies are all examples of: LTC policies limited risk policies special risk blanket policies 38. A Hospital Expense policy that pays a FLAT AMOUNT per day for hospital room and board pays benefits on what basis? Billing Reimbursement Automatic A fixed-rate plan 39. If one becomes totally disabled, Social Security Disability benefits: May begin after 30 days May begin after 60 days May begin after three months May begin after six months 40. Many major medical policies include a provision whereby when expenses reach a certain dollar amount, the insured no longer shares in the cost of expenses: the insurer pays 100% of remaining covered charges. This is referred to as the: maximum benefit benefit restoration coinsurance percentage stop-loss limit 41. When medical expense policies do not state specific dollar benefit amounts, but instead base payment upon the charges for the services in the same geographical area, benefits are designated as which of the following? Reasonable and Customary Approach Stated charges Percentage of stated charges Designated charges 42. Which of the following statements regarding workers' compensation plans is correct? Benefit amounts are mandated by the federal government A worker will qualify for benefits only if his disability or illness was a result of employer negligence Benefits may be financed by private insurers, state funds or self-insurance If a worker is killed in an industrial accident, his family is entitled to a specified benefit amount to pay for burial expenses 43. How long is the waiting period before a person may file a claim for Social Security Disability benefits? 12 Months 5 Months 90 Days 6 Months 44. Which statement concerning commercial companies is not true? They function on the reimbursement approach. They have a right of assignment built into many policies. They are not debit companies. May be monoline companies. 45. A policyowner has just informed the agent that she is younger than what was stated in the policy. The agent should: write a new policy at the correct age immediately so there will be no gap in coverage. notify the insurance company for a possible review of the application. notify the insurance company for a possible adjustment of the policy. determine whether there has been any change in health since the application for the policy. 46. Which of the following statements best describes an element of an insurable risk? 1. The loss must be due to chance. 2. The loss must be definite and measurable. 3. The loss must not be catastrophic. 4. The loss exposures to be insured must be large. 1 & 2 1, 2, & 3 2 & 3 All the above 47. What term describes the concept that the insurer and the insured share in the cost of medical expenses, with the insurer bearing the greater share? Deductible Stop-loss limit Coinsurance Benefit Restoration 48. What term describes the concept that the insurer and the insured share in the cost of medical expenses, with the insurer bearing the greater share? Deductible Stop-loss limit Coinsurance Benefit restoration 49. A Health Savings Account does not allow: Tax deductible contributions Tax free growth Tax free withdrawals non-qualified withdrawals 50. With regard to group insurance, who has the responsibility to apply for coverage, provide information about the group, maintain the policy, and pay premiums? The agent who wrote the group coverage The insurer that provides the group coverage The individuals that make up the group The master policy owner 51. Which of the following is not considered a "service provider"? Lloyds of London Blue Cross/ Blue Shield Health Maintenance Organizations Preferred Provider Organizations 52. What does the term PPO mean? Primary Physician On-Call Preferred Provider Organization Preferred Physicians of Ontario Potential Profitability Oscillation 53. An agent completes an application for accident and health insurance at the home of a proposed insured, collects the initial premium, and returns to her office. Before transmitting the application and premium to her home office, she finds an error. She should do which of the following? She should correct the error and have the insured initial it when the policy is delivered. She should complete and sign the agent's report. She should send a copy of the application to the Medical Information Bureau (MIB). She should go back to the insured and have him/her initial the change on the application. 54. Under the Basic Hospital Expense policy, what would not be covered under the miscellaneous expense benefit? anesthesia anesthesiologist use of the operating room drugs 55. The miscellaneous expense benefit in a basic hospital expense policy will cover physcian's bedside visits the administering of anesthesia drugs and medicine administered in the hospital hospital room and board 56. An insured has a basic hospital expense policy with a $10,000 limit for benefits, coordinated with a major medical policy with a $500 corridor deductible and 80/20 coinsurance provision. If she incurs a loss of $20,000, how much will the insurer pay? $16,000 $15,600 $8,000 $17,600 57. Which of the following statements concerning Blue Cross/Blue shield is/are correct? They are known as commercial insurers The physicians are pre-paid They operate on a capitation arrangement They have contractual arrangements with hospitals and physicians 58. When a medical expense policy pays benefits on an indeminty basis,it pays a certain percentage of whatever the hospital room charges are for total hospital expenses, less a deductible a flat amount per day for hospital room and board only for surgery and miscellaneous hospital expenses 59. All of the following statements about noncancellable policies are true except: A noncancellable policy is also called a noncancellable and guanteed renewable policy. The only right to cancel the noncancellable policy is for nonpayment of premiums. The insurer may increase the premium rate after the policy is in effect provided it does so by classes of insureds. The insurer may regain the right to cancel or not to renew when the insured reaches an age specified in the policy. 60. Rose Bud receives a hospital bill for $9,500 after being released from the hospital. Her Major Medical policy has a $500 deductible and an 80% - 20% continuous coinsurance feature. Of the total expense, how much will Rose have to pay? $1,800 $500 $2,300 $1,900 61. How does a basic medical plan avoid small claims and keep the cost of premiums down? by utilizing deductibles and co-insurance by imposing benefit limits by paying only catastrophic medical expenses by providing a network of physicians and hospitals 62. If all or part of a $500 deductible is offset by a Basic Medical policy, what type of deductible applies? integrated corridor flat split

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