Wisconsin Accident and Health Insurance Exam 2
2023/ 212 Questions and Answers/ Verified/
Graded A+
Alan is an enrollee of a health maintenance organization (HMO) which uses a
gatekeeper system. If there ever comes a time when he needs emergency health services,
what should he do?
Receive permission from the primary physician to begin treatment.
Call the HMO to verify coverage.
Proceed to the nearest emergency room.
Contact the HMO for a listing of approved providers. - -Proceed to the nearest
emergency room.
-What is a major difference between private commercial insurers and HMO's?
An HMO pays claims on a fee-for-service basis.
A private commercial insurer typically has fewer health provider choices.
An HMO combines medical care delivery and funding in one organization.
A private commercial insurer only offers individual coverage. - -An HMO combines
medical care delivery and funding in one organization
-Which of the following health plans pay benefits on a pre-paid service basis?
Medicare.
Medicaid.
Group medical expense.
HMO. - -HMO
, -In a staff model HMO, enrollees normally have which of the following pharmacy
options available to them?
Mail-order pharmacy.
In-house pharmacy.
Captive pharmacy.
Network pharmacies. - -In-house pharmacy.
-Inpatient psychiatric care is covered under Part A Medicare for 190 days per
Admission.
Year.
Benefit period.
Lifetime. - -Lifetime.
-An HMO prescription drug plan is generally characterized by
Generic drugs only.
Annual deductibles.
Drugs dispensed through participating pharmacies.
Drugs dispensed through online pharmacies. - -Drugs dispensed through participating
pharmacies.
-A characteristic of preferred provider organizations (PPO) is
PPOs operate like an HMO on a prepaid basis.
If service is obtained outside the PPO, benefits are reduced and costs increase.
PPOs are generally public in nature rather than private.
Health care providers themselves are barred from forming a PPO due to conflict of
interest. - -If service is obtained outside the PPO, benefits are reduced and costs
increase.
,-Individuals who participate in an HMO plan are called
Certificate holders.
Subscribers.
Policyowners.
Beneficiaries. - -Subscribers.
-Tim had an on-the-job accident and collects benefits from his individual disability
income policy. Which factor could possibly reduce these benefits?
State and federal income taxes.
Benefits he receives from workers compensation.
Total household income.
Assistance he receives from friends and family. - -Benefits he receives from workers
compensation.
-Which of these procedures is NOT designed for ambulatory care centers?
Inpatient surgery.
Vaccinations.
Outpatient surgery.
Physical examinations. - -Inpatient surgery.
-Specialty care is provided by which of the following health maintenance organization
(HMO) providers?
Neurologist.
HMO administrator.
HMO director.
Gatekeeper. - -Neurologist.
-A MET third-party administrator may NOT perform which of the following functions?
, Claims processing.
Marketing the plan.
Underwriting the plan.
Insuring the plan. - -Marketing the plan.
-The coinsurance for skilled nursing facility services covered by Medicare after the
100% Medicare coverage ends is
15% of the approved amount.
30% of the approved amount.
A percentage of the approved amount.
A flat dollar amount per day. - -A flat dollar amount per day.
-Ken is age 65 and has 2 years until he receives Social Security retirement income
benefits. At his current age, which is true about Medicare Part A Hospital Insurance
coverage?
It is available through application to Homeland Security.
It is available through application to Social Security.
He is automatically enrolled through his employer
He is not eligible until he starts receiving social security retirement income. - -It is
available through application to Social Security.
-Third-party administration has become fairly common in accident and health
insurance due to the growth of
The Affordable Care Act.
Self-funding of benefits.
Health savings accounts.
Medicaid. - -Self-funding of benefits.
2023/ 212 Questions and Answers/ Verified/
Graded A+
Alan is an enrollee of a health maintenance organization (HMO) which uses a
gatekeeper system. If there ever comes a time when he needs emergency health services,
what should he do?
Receive permission from the primary physician to begin treatment.
Call the HMO to verify coverage.
Proceed to the nearest emergency room.
Contact the HMO for a listing of approved providers. - -Proceed to the nearest
emergency room.
-What is a major difference between private commercial insurers and HMO's?
An HMO pays claims on a fee-for-service basis.
A private commercial insurer typically has fewer health provider choices.
An HMO combines medical care delivery and funding in one organization.
A private commercial insurer only offers individual coverage. - -An HMO combines
medical care delivery and funding in one organization
-Which of the following health plans pay benefits on a pre-paid service basis?
Medicare.
Medicaid.
Group medical expense.
HMO. - -HMO
, -In a staff model HMO, enrollees normally have which of the following pharmacy
options available to them?
Mail-order pharmacy.
In-house pharmacy.
Captive pharmacy.
Network pharmacies. - -In-house pharmacy.
-Inpatient psychiatric care is covered under Part A Medicare for 190 days per
Admission.
Year.
Benefit period.
Lifetime. - -Lifetime.
-An HMO prescription drug plan is generally characterized by
Generic drugs only.
Annual deductibles.
Drugs dispensed through participating pharmacies.
Drugs dispensed through online pharmacies. - -Drugs dispensed through participating
pharmacies.
-A characteristic of preferred provider organizations (PPO) is
PPOs operate like an HMO on a prepaid basis.
If service is obtained outside the PPO, benefits are reduced and costs increase.
PPOs are generally public in nature rather than private.
Health care providers themselves are barred from forming a PPO due to conflict of
interest. - -If service is obtained outside the PPO, benefits are reduced and costs
increase.
,-Individuals who participate in an HMO plan are called
Certificate holders.
Subscribers.
Policyowners.
Beneficiaries. - -Subscribers.
-Tim had an on-the-job accident and collects benefits from his individual disability
income policy. Which factor could possibly reduce these benefits?
State and federal income taxes.
Benefits he receives from workers compensation.
Total household income.
Assistance he receives from friends and family. - -Benefits he receives from workers
compensation.
-Which of these procedures is NOT designed for ambulatory care centers?
Inpatient surgery.
Vaccinations.
Outpatient surgery.
Physical examinations. - -Inpatient surgery.
-Specialty care is provided by which of the following health maintenance organization
(HMO) providers?
Neurologist.
HMO administrator.
HMO director.
Gatekeeper. - -Neurologist.
-A MET third-party administrator may NOT perform which of the following functions?
, Claims processing.
Marketing the plan.
Underwriting the plan.
Insuring the plan. - -Marketing the plan.
-The coinsurance for skilled nursing facility services covered by Medicare after the
100% Medicare coverage ends is
15% of the approved amount.
30% of the approved amount.
A percentage of the approved amount.
A flat dollar amount per day. - -A flat dollar amount per day.
-Ken is age 65 and has 2 years until he receives Social Security retirement income
benefits. At his current age, which is true about Medicare Part A Hospital Insurance
coverage?
It is available through application to Homeland Security.
It is available through application to Social Security.
He is automatically enrolled through his employer
He is not eligible until he starts receiving social security retirement income. - -It is
available through application to Social Security.
-Third-party administration has become fairly common in accident and health
insurance due to the growth of
The Affordable Care Act.
Self-funding of benefits.
Health savings accounts.
Medicaid. - -Self-funding of benefits.
