Deck 3: Basics of Health Insurance

Question 1

Mr. Talili has two medical insurance policies. To prevent duplication of payment for the same medical expense, the policies include a

A) coordination of benefits statement.
B) basic health insurance statement.
C) guaranteed benefit statement.
D) conditional benefit statement.

Answer 1

coordination of benefits statement.

Question 2

What is the correct term used to determine if a procedure is covered and medically necessary?

A) Preauthorization
B) Predetermination
C) Precertification
D) Verification

Answer 2

Preauthorization

Question 3

Most physician/patient contracts are

A) implied.
B) expressed.
C) written.
D) verbal.

Answer 3

implied.

Question 4

According to the birthday law, if both the mother and the father have the same birthday

A) the hour of birth determines who pays first.
B) the plan of the person who has coverage longer is the primary payer.
C) the plan that offers the best coverage is the primary payer.
D) the father's policy is the primary payer.

Question 5

Most legal issues of private health insurance claims fall under

A) federal law.
B) civil law.
C) regional law.
D) government laws.

Question 6

A policy in which the insurer cannot increase premium rates and must renew the policy until the insured reaches the age specified in the contract is a

A) cancelable policy.
B) conditionally renewable policy.
C) guaranteed renewable policy.
D) noncancelable policy.

Question 7

Conditions that existed and were treated before the health insurance policy was issued are called

A) accidents.
B) illnesses.
C) preexisting.
D) unforeseen occurrences.

Question 8

When does the physician/patient contract begin?

A) After the physician has examined the patient for the first time
B) When the patient steps into the examination room to be treated
C) When the physician accepts the patient and agrees to treat the patient
D) When the patient verbally agrees to accept the advice of the physician

Question 9

Why would conversion from a group policy to an individual policy be advantageous?

A) Premiums would be reduced.
B) Benefits would be increased.
C) No physician examination is required.
D) No precertification is necessary.

Question 10

Mr. Ott was laid off from his job. He is protected by the Consolidated Omnibus Budget Reconciliation Act (COBRA), which requires his employer to

A) pay him partial salary for 6 months.
B) extend group health insurance coverage for 18 months.
C) extend individual health insurance policies for 18 months.
D) pay him full salary for 6 months.

Question 11

The insured is always

A) the patient.
B) the person at risk.
C) the individual enrollee or organization protected.
D) the employer.

Question 12

In cases of divorce, the decision as to which parent should be responsible for payment of the child's services should be made by

A) the parents.
B) the provider.
C) the court system.
D) the claims adjudicator.

Question 13

An attachment to an insurance policy that excludes certain illnesses or disabilities that would otherwise be covered is referred to as a/an

A) waiver.
B) exclusion.
C) grace period.
D) deductible.

Question 14

In health insurance, the insured is also known as

A) the subscriber.
B) the member.
C) the policyholder.
D) all of the above.

Question 15

When a patient carries private medical insurance, the contract for treatment exists between

A) the patient and the insurance company.
B) the physician and the patient.
C) the physician and the insurance company.
D) the policyholder and the insurance company.

Question 16

The contract in a workers' compensation case exists between

A) the patient and the insurance company.
B) the physician and the patient.
C) the physician and the insurance company.
D) the policyholder and the insurance company.

Question 17

Mrs. Thompsett leaves her place of employment. She is eligible to transfer her medical insurance coverage from a group to an individual contract. This is known as

A) contract privilege.
B) conversion privilege.
C) coordination privilege.
D) exclusion privilege.

Question 18

The reason for a coordination of benefits statement in a health insurance policy is

A) to prevent duplication or overlapping of payments for the same medical expense.
B) to ensure adequate payment to the insured who holds more than one policy.
C) to ensure payment to the physician.
D) to make the insurance companies responsible for full payment of claims.

Question 19

If a child has health insurance coverage from two parents, according to the birthday law

A) the father's insurance is always primary.
B) the mother's insurance is always primary.
C) the health plan of the person whose birthday (month and day) falls earlier in the calendar year will pay first.
D) it is only in effect if the parents are divorced.

Question 20

An emancipated minor is

A) a person younger than the age of 18 who lives independently.
B) a person older than the age of 21.
C) a person younger than the age of 16 who lives with his or her parents.
D) a person younger than the age of 18 who does not live with his or her parents.

Question 21

A patient intake sheet is also called a

A) patient form.
B) patient report.
C) patient registration form.
D) medical record.

Question 22

What is the minimum number of employees a company must have to meet the criteria of the COBRA for continued medical benefits if an employee is laid off from a company?

A) 15
B) 20
C) 25
D) 50

Question 23

The person who is applying for insurance coverage is called the ____________________.

Question 24

An encounter form may also be known as a

A) ledger card or patient account.
B) daysheet or daily record sheet.
C) patient service slip.
D) fact sheet or face sheet.

Question 25

The first legal item in the business of handling medical insurance is the insurance ____________________ or policy.

Question 26

The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA), together, are commonly referred to as: ____________________________

Question 27

A daily record sheet used to record daily business transactions is called a/an

A) ledger.
B) encounter form.
C) daysheet.
D) transaction slip.

Question 28

A state and federal program for children who are younger than 21 years of age and have special health care needs is

A) Medicaid.
B) Children's Protective Services.
C) Medi-Medi.
D) Maternal and Child Health Programs (MCHP).

Question 29

A type of managed care organization created by the 1982 Tax Equity and Fiscal Responsibility Act (TEFRA) that allows for enrollment of Medicare beneficiaries into managed care plans is a/an

A) preferred provider organization (PPO).
B) competitive medical plan (CMP).
C) independent practice association (IPA).
D) point-of-service plan (POS).

Question 30

An organization of physicians, sponsored by a state or local medical association, concerned with the development and delivery of medical services and the cost of health care is known as a/an

A) competitive medical plan (CMP).
B) exclusive provider organization (EPO).
C) foundation for medical care.
D) independent practice association (IPA).

Question 31

The act created to protect workers and their families so that they can get and maintain health insurance if they change or lose their jobs is called the

A) Consolidated Omnibus Budget Reconciliation Act (COBRA).
B) Health Care Finance Administration Act (HCFAA).
C) Bush Fair Health Act (BFHA).
D) Health Insurance Portability and Accountability Act (HIPAA).

Question 32

An insurance claims register facilitates

A) follow-up of insurance claims.
B) registration of the patient.
C) determination of insurance coverage.
D) completion of the initial insurance form.

Question 33

An insurance policy is a legally enforceable agreement called a/an ____________________.

Question 34

When the physician's services have been submitted to the patient's insurance company by the physician's office, the patient should

A) not be sent a statement.
B) be sent a monthly statement indicating the insurance company has been billed.
C) be sent the first statement as soon as the insurance company has paid.
D) be expected to pay the physician and receive reimbursement from the insurance company.

Question 35

The source document for insurance claim data is the

A) ledger.
B) daysheet.
C) CMS-1500.
D) superbill.

Question 36

Assignment of benefits is

A) used only by nonparticipating physicians.
B) never used by participating physicians.
C) the transfer of the physician's right to collect an amount payable to the patient.
D) the transfer of one's legal right to collect an amount payable under an insurance contract.

Question 37

When a contract is not manifested by direct words but is deduced from the circumstance, the general language, or the conduct of the patient, it is referred to as a/an ____________________ contract.

Question 38

The first document obtained in the initial patient visit is a/an

A) encounter form.
B) patient chart.
C) patient information form.
D) patient ledger.

Question 39

Under HIPAA guidelines, physicians must send all claims electronically

A) if they have fewer than 25 full-time employees.
B) if they have more than 25 full-time employees.
C) if they have more than 10 full-time employees.
D) if they have fewer than 10 full-time employees.

Question 40

A key provision to the Affordable Care Act is the creation of central clearinghouses that offer "one-stop shopping" for purchasing health insurance coverage, which are known as: ____________________________

Question 41

When a payment is received, it is posted and ____________________ to the patient's account on the ledger card and current daysheet.

Question 42

If the premium of an insurance policy is not paid, a ____________________ from 10 to 30 days is usually given before insurance coverage is canceled.

Question 43

If an insurance policy states that pregnancy is not covered, the policy would list it as a/an ____________________.

Question 44

A state-sponsored program that provides free low-cost health coverage for low-income children is: ___________________________

Question 45

Discovering the maximum dollar amount that the carrier will pay for a procedure is called ____________________.

Question 46

The federal government can assess penalties for not collecting coinsurance for patients seen under the ________________ program.

Question 47

Many Health Insurance Claim Forms contain a/an ______________________________ that directs the insurance company to pay benefits directly to the provider of care on whose charge the claim is based.

Question 48

Match each type of health plan to its description.

Government-sponsored program that provides hospital and medical services for dependents of active duty uniform service members, military retirees and their families, and survivors of uniformed services.

A)Independent practice association (IPA)
B)Medicaid
C)State disability or Unemployment Compensation Disability (UCD)
D)TRICARE
E)Workers' compensation insurance
F)CHAMPVA
G)Health maintenance organization (HMO)
H)Disability income insurance
I)Medicare

Question 49

The patient registration/information form is also called a patient ____________________ sheet.

Question 50

When the insured is required to pay a percentage of the covered services' costs, this is referred to as ____________________.

Question 51

Electronic billers are permitted to obtain a ___________________ authorization from the patient to release medical information necessary to process a claim.

Question 52

The cost-sharing amount a managed care patient must pay at the point of arriving in the office is referred to as the ________________.

Question 53

A financial accounting record that is maintained for each patient who receives professional services is referred to as a/an ____________________.

Question 54

List the reasons that health care reform is necessary in the United States.

Question 55

A tax-free savings account that allows individuals and their employers to set aside money to pay for health care expenses is known as: _________________________________

Question 56

In a managed care plan, the participating provider is also referred to as: ___________________________

Question 57

The amount that must be paid each year by the insured before policy benefits begin is known as the ____________________.

Question 58

A form of health insurance that provides periodic payments to replace income when the insured is unable to work is: __________________________

Question 59

An insurance policy becomes effective only after the company offers the policy and the person accepts it and then pays the initial ____________________.

Question 60

The five classifications of health insurance policies are (1) cancelable, (2) optionally renewable, (3) conditionally renewable, (4) guaranteed renewable, and (5) ____________________.

Question 61

Match each type of health plan to its description.

A contract that insures a person against on-the-job injury or illness.

A)Independent practice association (IPA)
B)Medicaid
C)State disability or Unemployment Compensation Disability (UCD)
D)TRICARE
E)Workers' compensation insurance
F)CHAMPVA
G)Health maintenance organization (HMO)
H)Disability income insurance
I)Medicare

Question 62

Match each type of health plan to its description.

A program sponsored jointly by federal and state governments for medically indigent persons, aged individuals who meet certain financial requirements, and the disabled.

A)Independent practice association (IPA)
B)Medicaid
C)State disability or Unemployment Compensation Disability (UCD)
D)TRICARE
E)Workers' compensation insurance
F)CHAMPVA
G)Health maintenance organization (HMO)
H)Disability income insurance
I)Medicare

Question 63

Match each type of health plan to its description.

Provides coverage for spouses and children of veterans with total, permanent, service-connected disabilities or for the surviving spouses and children of veterans who died as a result of service-connected disabilities.

A)Independent practice association (IPA)
B)Medicaid
C)State disability or Unemployment Compensation Disability (UCD)
D)TRICARE
E)Workers' compensation insurance
F)CHAMPVA
G)Health maintenance organization (HMO)
H)Disability income insurance
I)Medicare

Question 64

Parents of a college student who is living away from home are liable for the medical expenses incurred by their financially dependent child.

Question 65

If Mary Smith goes to Dr. Baker's office and Dr. Baker gives Mary Smith professional services that she accepts, this is an expressed contract.

Question 66

Basic health insurance coverage includes benefits for skilled nursing facilities.

Question 67

The Supreme Court deemed the Affordable Care Act's requirement to require individuals to have health insurance coverage or face a penalty as unconstitutional.

Question 68

An insurance policy becomes effective after the person accepts the policy and signs the contract.

Question 69

Match each type of health plan to its description.

Insurance that covers off-the-job injury or sickness and is paid by deductions from a person's paycheck.

A)Independent practice association (IPA)
B)Medicaid
C)State disability or Unemployment Compensation Disability (UCD)
D)TRICARE
E)Workers' compensation insurance
F)CHAMPVA
G)Health maintenance organization (HMO)
H)Disability income insurance
I)Medicare

Question 70

Under the health care reform legislation of 2010, health plans must allow employees to keep their children on their plans until the child is 26 years old.

Question 71

Match each type of health plan to its description.

An organization that provides a wide range of comprehensive health care services for a specified group at a fixed periodic payment.

A)Independent practice association (IPA)
B)Medicaid
C)State disability or Unemployment Compensation Disability (UCD)
D)TRICARE
E)Workers' compensation insurance
F)CHAMPVA
G)Health maintenance organization (HMO)
H)Disability income insurance
I)Medicare

Question 72

Match each type of health plan to its description.

A medical capitation plan in which the treatment is delivered via a clinic or independent physician that provides a number of basic medical services for a fixed capitation payment per month.

A)Independent practice association (IPA)
B)Medicaid
C)State disability or Unemployment Compensation Disability (UCD)
D)TRICARE
E)Workers' compensation insurance
F)CHAMPVA
G)Health maintenance organization (HMO)
H)Disability income insurance
I)Medicare

Question 73

Health Benefit Exchanges will make the process of researching, comparing, and purchasing health insurance policies more difficult.

Question 74

Match each type of health plan to its description.

The hospital insurance system and supplementary medical insurance for those older than 65 years of age, created by the 1965 Amendments to the Social Security Act.

A)Independent practice association (IPA)
B)Medicaid
C)State disability or Unemployment Compensation Disability (UCD)
D)TRICARE
E)Workers' compensation insurance
F)CHAMPVA
G)Health maintenance organization (HMO)
H)Disability income insurance
I)Medicare

Question 75

An insurance billing specialist can escape liability by pleading ignorance.

Question 76

The insured may not necessarily be the patient seen for the medical service.

Question 77

The Patient Protection and Affordable Care Act (PPACA) will make health care available and affordable to Americans who are currently without insurance coverage.

Question 78

Match each type of health plan to its description.

A form of health insurance that provides periodic payments to replace income when the insured is unable to work as a result of illness, injury, or disease.

A)Independent practice association (IPA)
B)Medicaid
C)State disability or Unemployment Compensation Disability (UCD)
D)TRICARE
E)Workers' compensation insurance
F)CHAMPVA
G)Health maintenance organization (HMO)
H)Disability income insurance
I)Medicare

Question 79

The concept of managed care began in the 1930s when Montgomery Ward and Company offered it to their employees.

Question 80

A subscriber of an insurance policy may also be known as a policyholder.