Wisconsin Accident and Health Insurance Exam 2 with complete solutions.

WISCONSIN ACCIDENT AND HEALTH
INSURANCE EXAM 2



Alan48is48an48enrollee48of48a48health48maintenance48organization48(HMO)48which48uses48a
48gatekeeper48system.48If48there48ever48comes48a48time48when48he48needs48emergency48h
ealth48services,48what48should48he48do?

Receive48permission48from48the48primary48physician48to48begin48treatment.
Call48the48HMO48to48verify48coverage.
Proceed48to48the48nearest48emergency48room.
Contact48the48HMO48for48a48listing48of48approved48providers.48-48answer--
Proceed48to48the48nearest48emergency48room.

What48is48a48major48difference48between48private48commercial48insurers48and48HMO's?

An48HMO48pays48claims48on48a48fee-for-service48basis.
A48private48commercial48insurer48typically48has48fewer48health48provider48choices.
An48HMO48combines48medical48care48delivery48and48funding48in48one48organization.
A48private48commercial48insurer48only48offers48individual48coverage.48-48answer--
An48HMO48combines48medical48care48delivery48and48funding48in48one48organization

Which48of48the48following48health48plans48pay48benefits48on48a48pre-paid48service48basis?

Medicare.
Medicaid.
Group48medical48expense.
HMO.48-48answer--HMO

In48a48staff48model48HMO,48enrollees48normally48have48which48of48the48following48pharmac
y48options48available48to48them?

Mail-order48pharmacy.
In-house48pharmacy.
Captive48pharmacy.
Network48pharmacies.48-48answer--In-house48pharmacy.

Inpatient48psychiatric48care48is48covered48under48Part48A48Medicare48for4819048days48per

,Admission.
Year.
Benefit48period.
Lifetime.48-48answer--Lifetime.

An48HMO48prescription48drug48plan48is48generally48characterized48by

Generic48drugs48only.
Annual48deductibles.
Drugs48dispensed48through48participating48pharmacies.
Drugs48dispensed48through48online48pharmacies.48-48answer--
Drugs48dispensed48through48participating48pharmacies.

A48characteristic48of48preferred48provider48organizations48(PPO)48is

PPOs48operate48like48an48HMO48on48a48prepaid48basis.
If48service48is48obtained48outside48the48PPO,48benefits48are48reduced48and48costs48increas
e.
PPOs48are48generally48public48in48nature48rather48than48private.
Health48care48providers48themselves48are48barred48from48forming48a48PPO48due48to48confli
ct48of48interest.48-48answer--
If48service48is48obtained48outside48the48PPO,48benefits48are48reduced48and48costs48increas
e.

Individuals48who48participate48in48an48HMO48plan48are48called

Certificate48holders.
Subscribers.
Policyowners.
Beneficiaries.48-48answer--Subscribers.

Tim48had48an48on-the-
job48accident48and48collects48benefits48from48his48individual48disability48income48policy.48
Which48factor48could48possibly48reduce48these48benefits?

State48and48federal48income48taxes.48
Benefits48he48receives48from48workers48compensation.48
Total48household48income.
Assistance48he48receives48from48friends48and48family.48-48answer--
Benefits48he48receives48from48workers48compensation.

Which48of48these48procedures48is48NOT48designed48for48ambulatory48care48centers?

Inpatient48surgery.
Vaccinations.
Outpatient48surgery.

,Physical48examinations.48-48answer--Inpatient48surgery.

Specialty48care48is48provided48by48which48of48the48following48health48maintenance48organi
zation48(HMO)48providers?

Neurologist.
HMO48administrator.
HMO48director.
Gatekeeper.48-48answer--Neurologist.

A48MET48third-
party48administrator48may48NOT48perform48which48of48the48following48functions?

Claims48processing.
Marketing48the48plan.
Underwriting48the48plan.
Insuring48the48plan.48-48answer--Marketing48the48plan.

The48coinsurance48for48skilled48nursing48facility48services48covered48by48Medicare48after48t
he48100%48Medicare48coverage48ends48is

15%48of48the48approved48amount.
30%48of48the48approved48amount.
A48percentage48of48the48approved48amount.
A48flat48dollar48amount48per48day.48-48answer--A48flat48dollar48amount48per48day.

Ken48is48age486548and48has48248years48until48he48receives48Social48Security48retirement48in
come48benefits.48At48his48current48age,48which48is48true48about48Medicare48Part48A48Hospit
al48Insurance48coverage?

It48is48available48through48application48to48Homeland48Security.
It48is48available48through48application48to48Social48Security.
He48is48automatically48enrolled48through48his48employer
He48is48not48eligible48until48he48starts48receiving48social48security48retirement48income.48-
48answer--It48is48available48through48application48to48Social48Security.


Third-
party48administration48has48become48fairly48common48in48accident48and48health48insuranc
e48due48to48the48growth48of

The48Affordable48Care48Act.
Self-funding48of48benefits.
Health48savings48accounts.
Medicaid.48-48answer--Self-funding48of48benefits.

, Tonya48has48been48diagnosed48with48kidney48failure48and48is48covered48by48group48accide
nt48and48health48insurance48through48her48large48employer.48Which48of48these48accident48
and48health48plans48will48be48primary48during48the48months48immediately48following48her48
diagnosis?

Medicare.
Medicaid.
Medicare48Supplement.
Her48employer's48group48accident48and48health48plan.48-48answer--
Her48employer's48group48accident48and48health48plan.

Employees48generally48receive48workers48compensation48benefits48for

Only48medical48expenses48due48to48occupational48accidents.
Employment48termination.
Lost48wages48and48medical48expenses48due48to48occupational48accidents.
Only48lost48wages48due48to48accidents48that48occur48on48the48job48-48answer--
Lost48wages48and48medical48expenses48due48to48occupational48accidents.

Where48does48the48primary48funding48for48Medicare48Part48A48come48from?

Private48funding.
Insurance48company48funding.
State48funding.
Federal48payroll48and48self-employment48taxes.48-48answer--Federal48payroll48and48self-
employment48taxes.

What48is48the48maximum48Social48Security48Disability48benefit48amount48an48insured48can4
8receive?


50%48of48the48insured's48Primary48Insurance48Amount48(PIA).
75%48of48the48insured's48Primary48Insurance48Amount48(PIA).
100%48of48the48insured's48Primary48Insurance48Amount48(PIA).
100%48of48the48insured's48Primary48Insurance48Amount48(PIA)48minus48any48monies48rece
ived48from48a48retirement48plan.48-48answer--
100%48of48the48insured's48Primary48Insurance48Amount48(PIA).

Medicare48can48be48described48as

A48supplemental48income48source48for48individuals48over48the48age48of486548or48permanen
tly48disabled.
A48state48health48program48for48individuals48over48the48age48of486548or48permanently48disa
bled.
A48federal48health48program48for48individuals48with48financial48need.
A48federal48health48insurance48program48for48individuals48over48the48age48of486548or48perm
anently48disabled.48-48answer--