Accidental & Health Exam Cram #1 Flashcards
1
Q
- A Long - Term Care insurance rider can include coverage
for all of the following EXCEPT
a. Hospice.
b. Respite care.
c. Adult day care.
d. Hospital acute care.
A
Hospital acute care
2
Q
- What is the purpose of social insurance?
a. To allow people to choose the coverages thy want.
b. To reward individuals for their loyalty and longevity.
c. To prevent some individuals from earning too much money.
d. To protect certain vulnerable segments of the population.
A
To protect certain vulnerable segments of the population
3
Q
- All of the following may opt for a self insured medical and disability plan EXCEPT
a. Co-ops.
b. Fraternals.
c. Individuals.
d. Labor unions.
A
Individuals
4
Q
- What rights do individuals have if they disagree with a decision on the amount Medicare will pay?
a. They can change Medicare carriers.
b. They can ask a Medicare carrier to review the decision.
c. They can request a second opinion by the state medical examiner.
d. They can terminate making premium payments until the claim is resolved.
A
They can ask a Medicare carrier to review the decision.
5
Q
- After the deductible, what portion does a patient pay for covered expenses under Medicare Part B?
a. 20%
b. 50%
c. 80%
d. 100%
A
20%
6
Q
- Regarding the Health Benefit Exchanges, as created by PPACA, all of the following statements are true EXCEPT
a. The name of California’s Exchanges is Covered California.
b. An individual enrolling in a bronze level plan is not eligible for reduced cost-sharing.
c. An individual whose household income is 400% of the federal poverty level may receive a premium tax credit.
d. An individual may only receive a premium tax credit for a plan if purchased through the Exchange.
A
An individual enrolling in a bronze level plan is not eligible for reduced cost-sharing
7
Q
- A Health insurance issuer offering coverage in the individual market must provide premium rebates if its
medical loss ratio (MLR) is less than what percentage?
a. 70%
b. 75%
c. 80%
d. 85%
A
80%
8
Q
- Which of the following statements concerning the usual coordination of benefits provision is correct?
a. Medicare coverage is always primary to medical coverage.
b. Coverage under COBRA is primary to coverage as an active employee.
c. When two plans both have the provision, coverage as an employee is primary to coverage as a dependent.
d. Coverage under any plan with the provision is primary to coverage under any plan without the provision
A
When two plans both have the provision, coverage as an employee is primary to coverage as a dependent.
9
Q
- In medical expense insurance, what serves the same purpose as the elimination period in disability income
insurance?
a. Coinsurance.
b. Co-payment.
c. Deductible.
d. Maximum benefit.
A
Deductible
10
Q
- Which plan covers the medical expenses that are NOT covered by Medicare?
a. Medi-cal.
b. Long-term care.
c. Disability income.
d. Medicare supplement.
A
Disability income
11
Q
- What is the first step in submitting Medicare claims?
a. The patient submits expenses to Medicare.
b. The medical provider submits expenses to Medicare.
c. The medical provider submits expenses to the patient.
d. Medicare submits expenses to the Medicare supplement provider.
A
The medical provider submits expenses to Medicare
12
Q
- In the absence of a coordination of benefits clause, all of the following circumstances might result in recovery of more than 100% of actual health care expenses EXCEPT:
a. A person working for two employers has health insurance through both.
b. Spouses are both employed and eligible for group medical benefits.
c. An executive has additional coverage though an association policy.
d. Worker’s medical plan includes a carryover deductible provision.
A
Worker’s medical plan includes a carryover deductible provision.
13
Q
- Provisions in a disability income policy include all of the following EXCEPT
a. Indemnity amount.
b. Elimination period.
c. Maximum benefit period.
d. Deductible and coinsurance amounts.
A
Deductible and coinsurance amounts.
14
Q
- Which of the following is NOT an example of cost
sharing in a health insurance policy?
a. Coinsurance.
b. Coordination.
c. Copayment.
d. Deductible.
A
Coordination
15
Q
- An example of the third-party administrator is an
a. Employee who is responsible for evaluating the relative quality of competing group health and welfare benefits offered to her employer by insurers.
b. Outside organization that processes claims for an employer’s self-funded group plan.
c. Agent’s supervisor who takes part of his commission.
A
Outside organization that processes claims for an employer’s self-funded group plan.
16
Q
- Why is an injury caused by an accident at an employee’s
workplace excluded from individual health insurance coverage?
a. It is covered by the employer’s group disability insurance plan.
b. It is covered by the employer’s group health insurance plan.
c. It is covered by the state Worker’s Compensation program.
d. It is covered by Social Security benefits.
A
It is covered by the state Worker’s Compensation program.
17
Q
- The adult day care coverage level of the long-term care policy provides for
a. Part-time home health care for the frail elderly.
b. Full-time nursing at home for a convalescent elder.
c. Part-time nursing at a facility for elderly who live at home.
d. Full-time nursing care for elders who live in assisted living centers.
A
Part-time nursing at a facility for elderly who live at home.
18
Q
- Under group disability insurance an employee is eligible for a partial disability benefit when they can
a. No longer work full or part time because of an accidental injury.
b. Collect adjusted lost wages while on leave of absence due to illness.
c. Demonstrate their inability to perform due to loss of sight in one eye.
d. Perform some of their job activities on a part time basis after injury.
A
Perform some of their job activities on a part time basis after injury
19
Q
- Two of the long-term care chronically ill activities of daily
living (ADLs) are
a. Eating and dressing
b. Bathing and hearing
c. Sleeping and walking
d. Speaking and incontinence.
A
Eating and dressing
20
Q
- Vision insurance usually limits coverage in all of the following ways EXCEPT
a. One examination per year.
b. One set of lenses per year.
c. A specific dollar amount for frames.
d. A specific dollar amount for examinations
A
A specific dollar amount for examinations
21
Q
- Medicare part A provides coverage for all of the following
EXCEPT
a. Physicians’ services.
b. Hospitalization.
c. Home health care.
d. Hospice.
A
Physicians’ services
22
Q
- What happens if an insurer violates the Medical Loss Ratio rule and spends too much money on administrative
costs?
a. Insurers that do not meet the Medical Loss Ratio standard will be required to provide rebates to their
customers and reduce spending on their administrative costs.
b. Insurers that do not meet the Medical Loss Ratio standard will pay a tax penalty to the Federal government.
c. Insurers that do not meet the Medical Loss Ratio standard will pay a tax penalty to the Health Benefit
Exchange.
d. Insurers that do not meet the Medical Loss Ratio standard will only be required to reduce their spending
on administrative costs.
A
Insurers that do not meet the Medical Loss Ratio standard will be required to provide rebates to their
customers and reduce spending on their administrative costs.
23
Q
- The type of health care provider that provides both the health care services and health care coverage is called
a. A preferred provider Organization.
b. A Health Maintenance Organization.
c. A major medical organization.
d. An EPO.
A
A Health Maintenance Organization.
24
Q
- In California, a child may obtain individual health coverage through all of the following EXCEPT
a. Medi-Cal (California’s Medicaid)
b. Direct from insurance carrier.
c. Covered California.
d. Healthy families.
A
Healthy families.
25
25. Which program is designed to provide medical assistance to people with low incomes?
a. Medi-Cal.
b. Medicare.
c. Social Security.
d. Worker's Compensation.
Medi-Cal
26
26. The premium of a proposed disability income policy could
be lowered by increasing the
a. Benefit period.
b. Monthly benefit.
c. Elimination period.
d. Cost-of- living rider benefit.
Elimination period
27
27. Which health insurance provision protects an insured from the expense of a catastrophic illness?
a. Exclusion.
b. Deductible.
c. Coinsurance.
d. Stop-loss.
Stop-loss
28
28. Which health insurance provision protects an insured from the expense of a catastrophic illness?
a. Exclusion.
b. Deductible.
c. Coinsurance.
d. Stop-loss.
Stop-loss
29
29. The initial enrollment period for Medicare Part B ends how many months after the 65 birthday month?
a. One month.
b. Three months.
c. Five months.
d. Seven months.
Three months
30
30. In health insurance the coinsurance is
a. A percentage of the cost for covered expenses paid by more than one insurer.
b. A portion of the premium paid by the insured and insurer for each covered service.
c. A payment shared by the insured and provider of covered service minus the deductible.
d. A percentage paid for covered expenses by insured and insurer after the deductible is satisfied.
A percentage paid for covered expenses by insured and insurer after the deductible is satisfied.
31
31. Benefits under Social Security are available only for workers who are
a. Fully insured.
b. Medicare insured.
c. Currently insured.
d. Disability insured.
Fully insured
32
32. Which health insurance contract provision addresses the problem of overinsurance?
a. Reinstatement.
b. Incontestability.
c. Assignment of benefits.
d. Coordination of benefits.
Coordination of benefits
33
33. Which statement about Medicare is NOT correct?
a. Medicare part A covers hospital care.
b. Medicare part C covers long-term care.
c. Medicare part B covers physician services.
d. Medicare is a federal health insurance program.
Medicare part C covers long-term care.
34
34. Group health plans obligated by the Consolidated Omnibus Budget Reconciliation Act (COBRA) cover
groups of at least.
a. 10 employees.
b. 20 employees.
c. 40 employees.
d. 60 employees.
20 employees
35
35. For Social Security purposes, a person with 40 quarters of coverage is considered
a. Fully insured.
b. Partially insured.
c. Currently insured.
d. Conditionally insured.
Fully insured.
36
36. During the solicitation of a long term care insurance rider, a life agent must consider all of the following EXCEPT the applicant's
a. Goals and needs.
b. Attending physician statement.
c. Ability to pay for the coverage.
d. Existing long term care coverage.
Attending physician statement
37
37. Characteristics of preferred provider organizations (PPOs)
include all of the following EXCEPT
a. Primary physicians serve as gatekeepers.
b. There are incentives to use network providers.
c. Employees can see specialists without referrals.
d. Benefits are paid for care received by non-network physicians.
Primary physicians serve as gatekeepers.
38
38. According to the California insurance code, all of the following long-term care (LTC) insurance sales are considered unnecessary EXCEPT
a. A replacement LTC policy with equal benefits for a lower premium.
b. A replacement LTC policy with fewer benefits and a higher premium.
c. An additional LTC policy to an insured who already has two LTC policies.
d. Two additional LTC policies that equal the combined benefits on an existing one.
A replacement LTC policy with equal benefits for a lower premium.
39
39. An individual is allowed to enroll in individual health insurance under the following circumstances EXCEPT
a. At any time for Medi-Cal
b. Within 60 days of a qualifying event.
c. During the annual open enrollment period.
d. Within 30 days of being diagnosed with an illness.
Within 30 days of being diagnosed with an illness.
40
40. Which health plan pays more for care received form a network provider than it pays for care from a non-network provider?
a. Exclusive provider organization (EPO).
b. Health maintenance organization (HMO).
c. Preferred provider organization (PPO).
d. Major medical.
Preferred provider organization (PPO).
41
41. Providers of coverage for all of the following types of care are subject to the jurisdiction of the California department of insurance (CDI) EXCEPT
a. Lasik.
b. Chiropractic.
c. Dental.
d. Surgical.
Lasik
42
42. Under a disability income insurance policy with an own occupation clause, an individual who can no longer
perform the tasks of the job held at the time of injury is considered
a. Presumptively disabled.
b. Medically disabled.
c. Gainfully disabled.
d. Totally disabled.
Totally disabled
43
43. Traditional comprehensive major medical plans include all of the following EXCEPT
a. Coinsurance.
b. Deductibles.
c. First-dollar coverage.
d. Out-of-pocket maximums.
First-dollar coverage
44
44. After the deductible is satisfied, what percentage of a reasonable charge does Medicare part B pay?
a. 20%
b. 40%
c. 80%
d. 100%
80%
45
45. Health insurance counseling and advocacy program (HICAP) counselors can do all of the following EXCEPT
a. Help evaluate policies.
b. Charge for their services.
c. Assist in medical record keeping.
d. Explain Medicare supplement coverages.
Charge for their services
46
46. When medical expense policies do not state specific dollar benefit amounts, but instead base payments upon the charges for life services in the same geographical area, benefits are designated as
a. Usual, customary, and reasonable charges.
b. A percentage of stated charges.
c. Designated charges.
d. Stated charges.
Usual, customary, and reasonable charges.
47
47. Which type of insurance can be purchased at airports, bus terminals, and railroad stations?
a. Temporary life insurance.
b. Travel accident insurance.
c. Temporary health insurance
d. Accidental death and dismemberment.
Travel accident insurance
48
48. Residual disability income insurance payments are based on
a. An amount agreed upon by the insurer and the insured.
b. The amount the insured's income is reduced by the disability.
c. The amount necessary to induce the insured to go back to work.
d. The amount needed to continue the insured's standard of living.
The amount the insured's income is reduced by the disability.
49
49. The family and Medical leave Act (FMLA) covers all of the following EXCEPT
a. The adoption of a child.
b. Caring for a parent with a serious health condition.
c. Traveling with a spouse who has been transferred overseas.
d. A serious health condition that prevents an employee from working.
Traveling with a spouse who has been transferred overseas
50
50. A supplemental insurance policy that pays a set amount for each day that an individual is hospitalized is known as
a. Temporary major medical.
b. Long-term care supplement.
c. Hospital surgical expense.
d. Hospital confinement indemnity.
Hospital confinement indemnity.
51
51. The most common type of specified disease insurance policy is
a. Cancer.
b. Cataract.
c. Diabetes.
d. Heart disease.
Cancer
52
52. The Employee retirement income Security Act of 1974 (ERISA) regulates group health insurance in the area of
a. Family and medical leave.
b. Disclosure and reporting.
c. Americans with disabilities.
d. Continuation of group health care.
Disclosure and reporting.
53
53. All of the following statements are true regarding health insurance counseling advocacy program (HICAP)
counselors EXCEPT HICAP counselors
a. Provide information about the Medicare program.
b. Must complete an intensive training program.
c. Are qualified to give legal advice.
d. Are volunteers.
Are qualified to give legal advice.
54
54. Which group provides information about health-related issues to the elderly in California?
a. Medicare supplement insurers.
b. Long-term care insurance providers.
c. The National health care anti-fraud association.
d. The health insurance counseling and advocacy program(HICAP).
The health insurance counseling and advocacy program(HICAP).
55
55. With Medicare coverage
a. Benefits are available only to persons age 55 or older.
b. Both part A and part B provide benefits for care in skilled nursing facilities.
c. Part A has no deductibles or coinsurance for the first 60 days of hospitalization.
d. Part B provides benefits for diagnostic tests and X-rays performed on an outpatient basis.
Part B provides benefits for diagnostic tests and X-rays performed on an outpatient basis.
56
56. All of the following types of insurance pay benefits in addition to those paid by other insurance policies held by the insured EXCEPT
a. Medical expense.
b. Critical illness.
c. Specified disease.
d. Hospital indemnity.
Medical expense
57
57. All of the following are optional group medical coverages
EXCEPT
a. Dental.
b. Maternity.
c. Prescription drug.
d. Vision.
Maternity
58
58. A commonly used cost containment measure for emergency hospital care under a major medical expense
plan is the
a. Deductible.
b. Premium tax.
c. Inpatient fee.
d. Pre-admission test.
Deductible
59
59. The group medical plan provision that applies when a claimant has coverage under more than one plan is known as
a. Coinsurance.
b. Integration.
c. Maximum benefits.
d. Coordination of benefits.
Coordination of benefits
60
60. Vision care insurance usually covers all of the following EXCEPT
a. Eye surgery.
b. Contact lenses.
c. Eyeglass frames.
d. Eye examinations.
Eye surgery
61
61. Under the PPACA, which medical enrollment tier is 80% actuarial value?
a. Bronze.
b. Gold.
c. Platinum.
d. Silver.
Gold
62
62. The insurer can do which of the following under a noncancelable health insurance policy?
a. Raise the premium rate.
b. Change the policy provisions.
c. Refuse to renew the policy for any reason.
d. Cancel the policy for nonpayment of premium.
Cancel the policy for nonpayment of premium.
63
63. What is the cost of service from the health insurance counseling advocacy program (HICAP)?
a. $10 per appointment.
b. $25 per appointment.
c. $50 per appointment.
d. No charge.
No charge
64
64. In order to obtain group insurance without providing evidence of insurability, what do eligible individuals
generally have to do?
a. Submit an attending physician's statement with their group enrollment cards.
b. Enroll within a specified eligibility period,
c. Pay the first year premium in advance.
d. Nothing.
Enroll within a specified eligibility period,
65
65. As established by PPACA, an adult child may be covered by a parent's health insurance plan until what age?
a. 19 years old
b. 23 years old
c. 25 years old
d. 26 years old
26 years old
66
66. Part-time nursing care that follows a hospitalization and can be provided in a patient's home is covered under
a. Hospice benefits.
b. Respite benefits.
c. Urgent care benefits.
d. Home health care benefits.
Home health care benefits.
