Health Insurance and Medicaid Quiz
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Questions and Answers

Who is eligible for Medicaid based on income level?

  • Individuals who are eligible for Medicare
  • Individuals who have employer coverage
  • Individuals making under 100% of the Federal Poverty Level
  • Individuals making between 100-400% of the Federal Poverty Level (correct)

What type of organization provides life insurance primarily for mutual benefit with a social structure?

  • Fraternal associations (correct)
  • Mutual companies
  • Insurance syndicates
  • Stock companies

What do members typically pay in an HMO plan?

  • Only when they use the plan
  • A fixed premium whether or not the plan is used (correct)
  • A fluctuating premium based on usage
  • A premium based solely on the deductible

Which statement is true regarding Medicare beneficiaries joining an HMO?

<p>They must be informed about getting benefits from a Medicare Advantage plan (B)</p> Signup and view all the answers

What is a key condition regarding 'extension of benefits' for disabled individuals in an HMO?

<p>Coverage ends after 18 months (D)</p> Signup and view all the answers

What must Florida HMO members expect regarding coverage policies?

<p>Terms of coverage are subject to change without notice (D)</p> Signup and view all the answers

What happens to coverage if a member is no longer totally disabled?

<p>Coverage ends immediately (B)</p> Signup and view all the answers

Which group cannot be eligible for Medicare?

<p>Individuals with employer-sponsored insurance (D)</p> Signup and view all the answers

How much will Casey's medical expense policy pay after being hospitalized for 10 days at a fixed rate of $150 per day?

<p>$1,500 (A)</p> Signup and view all the answers

What amount will Jamie's reimbursement type medical expense policy cover if she incurs $25,000 in medical expenses?

<p>$25,000 (A)</p> Signup and view all the answers

Which of the following costs will not be covered under the 'Miscellaneous Expenses' of a hospital expense policy?

<p>Daily room and board (B)</p> Signup and view all the answers

Which approach is NOT used by insurers for providing basic surgical expense coverage?

<p>Physician schedule approach (D)</p> Signup and view all the answers

If Charlie incurs $1,500 in miscellaneous expenses during his hospitalization, how much will his hospital expense policy cover?

<p>$1,000 (D)</p> Signup and view all the answers

What is the total payment from Charlie's policies if he has $200 per day room and board charges for 10 days?

<p>$2,000 (B)</p> Signup and view all the answers

If Charlie's surgical policy pays a maximum of $500 for any operation and he incurs $2,000 for surgical expenses, how much will he get compensated?

<p>$500 (C)</p> Signup and view all the answers

What is the total amount of medical expenses that Casey's and Jamie's policies will cover combined if Casey's expenses total $20,000 and Jamie's total $25,000?

<p>$26,000 (D)</p> Signup and view all the answers

What amount will Peter receive in monthly benefit payments due to his partial disability?

<p>$800 (D)</p> Signup and view all the answers

How much can Joseph expect to receive from his disability income policy after returning to work part-time?

<p>$1,000 monthly benefit (D)</p> Signup and view all the answers

Which form of insurance primarily offers pure accident coverage?

<p>Accidental Death and Dismemberment (D)</p> Signup and view all the answers

Which type of loss is NOT covered by George's Accident, Death, and Dismemberment policy?

<p>Broken arm (A)</p> Signup and view all the answers

What does the principal sum represent in an Accidental Death and Dismemberment policy?

<p>The maximum benefit for accidental death (D)</p> Signup and view all the answers

If Peter's disability income policy states he can receive residual disability benefits of $2,000, what percentage of his predisability income does this represent?

<p>40% (D)</p> Signup and view all the answers

What portion of his total disability benefit does Peter lose if he is earning 60% of his predisability salary?

<p>40% (A)</p> Signup and view all the answers

Which of the following best describes the benefit calculation in residual disability policies?

<p>Percentage of lost income multiplied by total disability benefit (D)</p> Signup and view all the answers

What role does a Third Party Administrator primarily serve?

<p>Acts as a liaison between the insurer and employer (B)</p> Signup and view all the answers

If Sylvia chooses a non-preferred provider while enrolled in a PPO, what is the likely outcome?

<p>The PPO will pay a reduced amount with Sylvia covering the difference. (D)</p> Signup and view all the answers

Which statement about traditional commercial insurers is TRUE?

<p>They market reimbursement type contracts paying directly to the insured. (A)</p> Signup and view all the answers

What does the term 'Insurance Transaction' encompass?

<p>Engaging in negotiations (A)</p> Signup and view all the answers

A policy that covers various medical expenses, including inpatient visits, is known as which type of policy?

<p>Medical Expense Policy (B)</p> Signup and view all the answers

In Ed and Mavis's Major Medical Policy, which provision indicates that benefits can be restored after they have been used?

<p>Restoration of Benefits Provision (C)</p> Signup and view all the answers

What is the purpose of the Carry-Over Provision in Ed and Mavis's policy?

<p>To apply previous expenses toward future deductibles (B)</p> Signup and view all the answers

What is a characteristic of the Major Medical Policy that Ed and Mavis hold?

<p>It features 80/20 coinsurance rates. (D)</p> Signup and view all the answers

What is a benefit payment from a Hospital Income or Indemnity Policy?

<p>A cash amount based on hospitalization duration (B)</p> Signup and view all the answers

Which policy combines Basic Medical Expense Coverage with Major Medical Coverage?

<p>Comprehensive Major Medical (C)</p> Signup and view all the answers

What does UCR stand for in insurance terminology?

<p>Usual Customary and Reasonable (D)</p> Signup and view all the answers

Which policy utilizes a Corridor Deductible after Basic Medical Expense Coverage?

<p>Supplementary Major Medical (B)</p> Signup and view all the answers

Which type of policy would cover expenses for a broken hip?

<p>Medical Expense Policy (C)</p> Signup and view all the answers

Jasper's policy combines features of Basic Plans and Major Medical Insurance. What type of policy does he have?

<p>Comprehensive Major Medical Policy (C)</p> Signup and view all the answers

Which of the following best describes a cash payment from an insurance policy?

<p>A direct cash benefit during hospitalization (A)</p> Signup and view all the answers

In what scenario would a Comprehensive Major Medical Policy be beneficial?

<p>When there's a need for both basic and major medical coverage (D)</p> Signup and view all the answers

What option allows the insurer to deduct unpaid premiums from a claim?

<p>Unpaid Premiums (A)</p> Signup and view all the answers

Which sequence describes the duration of the grace period for premium payments?

<p>7 days weekly, 10 days monthly, 31 all others (C)</p> Signup and view all the answers

Which term and definition pair is incorrectly matched?

<p>Cancellable - the policy can be renewed at discretion (D)</p> Signup and view all the answers

Which clause specifies the coverage amount and conditions under a policy?

<p>Insuring Clause (D)</p> Signup and view all the answers

What might be a consequence for Susan who failed to pay her insurance premium?

<p>Deduction of unpaid premiums from her claim (A)</p> Signup and view all the answers

Under what circumstance may an insurer request a physical exam or autopsy?

<p>At their expense and if permitted by law (D)</p> Signup and view all the answers

Which option describes an aspect of a Guaranteed Renewable policy?

<p>Renewable without proof of insurability (B)</p> Signup and view all the answers

What specifies the conditions under which Jim is covered and the maximum policy limit?

<p>Insuring Clause (A)</p> Signup and view all the answers

Flashcards

Health Maintenance Organization (HMO)

A type of health insurance plan that provides coverage for medical services through a network of healthcare providers. Members typically pay a fixed monthly premium and a co-payment for each service.

Fixed Rate Hospitalization Policy

A type of medical expense policy that pays a fixed amount per day for hospitalization, regardless of the actual medical expenses incurred.

HMO Plan

A health insurance plan that provides comprehensive medical care to its members for a fixed monthly premium, regardless of how often they use the plan.

Reimbursement Type Medical Expense Policy

A type of medical expense policy that reimburses the policyholder for actual medical expenses incurred, up to a maximum limit.

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Hospital Expense Policy

A type of medical expense policy that covers a wide range of medical expenses, including hospitalization, surgery, and other miscellaneous expenses.

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Medicare Advantage Plan

A type of health insurance plan offered by private companies that can provide coverage to people who are eligible for Medicare. These plans offer a blend of benefits usually covered under Medicare, but with stricter limitations and some co-pays.

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Extension of Benefits

A period of time where coverage may continue for a person who is disabled under their HMO policy, even though they are no longer paying premiums.

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Surgical Expense Policy

A type of medical expense policy that covers the costs of surgical procedures.

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Reasonable and Customary Approach

A common approach for calculating surgical expense benefits. It considers the average cost of a specific surgical procedure in a particular geographic location and time period.

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Mutual Company

A kind of insurance company that is run by and for its policyholders. Its members pay premiums and share in the company's profits.

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Fraternal Association

A group that offers life insurance primarily to its members, often with a lodge or social system. It's a type of insurance company that serves its members and provides them with financial security.

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Surgical Schedule Approach

An approach for calculating surgical expense benefits that uses a predetermined schedule of fees for different surgical procedures.

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Relative Value Scale Approach

A common approach used to calculate surgical expense benefits. It assigns a value to different medical procedures based on their complexity and resources used.

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Who Can Be Eligible for Medicaid?

A person who cannot be covered by an employer-sponsored health plan and meets the eligibility requirements for Medicaid.

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Medicare Eligibility for HMO

Individuals who are eligible for Medicare and wish to join an HMO must be informed that the HMO plan will be providing all of the benefits they'd receive under Medicare.

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Medicaid Program

A health insurance plan that offers low-cost or free coverage based on income and family size for eligible individuals.

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Residual Disability Benefit

A type of disability income policy payment where the benefit is calculated based on the percentage of income lost due to partial disability.

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Accidental Death and Dismemberment (AD&D)

This type of insurance provides coverage for specific, accidental events, particularly death or dismemberment.

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Principal Sum

A fixed amount paid out by an AD&D policy in case of death from an accident. It's a primary benefit.

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Disability Income Insurance

Disability income insurance pays benefits to replace lost income due to an inability to work because of a disability.

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Partial Disability

The ability of an individual to work only part-time, meaning they can't perform their usual work at full capacity.

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Dismemberment

The loss of bodily function or a limb due to an accidental injury.

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Total Disability

The scenario where an individual can't perform their usual work at all.

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Predisability Income

The amount of income an individual earned before becoming disabled. Usually based on their salary.

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Hospital Income or Indemnity Policy

A type of health insurance that pays a fixed amount per day for hospitalization, regardless of actual medical expenses.

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Comprehensive Major Medical Policy

This type of policy combines basic medical coverage with major medical coverage, offering the most complete hospital coverage.

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Usual, Customary, and Reasonable (UCR)

A system that uses the average fee charged by doctors in a specific geographic area to determine insurance reimbursements.

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Supplementary Major Medical Policy

A type of health insurance that provides additional coverage on top of a basic medical plan, kicking in after a specific deductible is met.

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Medical Expense Policy

A type of health insurance that covers expenses related to accidents and health issues, including things like a broken hip.

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Comprehensive Major Medical Policy

This type of policy combines the best features of basic medical plans and major medical insurance, providing comprehensive hospital coverage.

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Hospital Income or Indemnity Policy

A policy that pays a benefit directly to the insured, usually a fixed amount per day, during hospitalization.

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Usual, Customary, and Reasonable (UCR)

An approach to calculating surgical expense benefits that considers the typical cost of a procedure in a specific area and time period.

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What is a Third Party Administrator?

A third party administrator (TPA) acts as a middleman between an insurer and an employer, handling administrative tasks like processing claims, managing benefits, and communicating with both parties.

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What is Administrative Services Only (ASO)?

Administrative Services Only (ASO) is an arrangement where an employer outsources some or all of its employee benefits administration to a TPA, while still retaining the financial responsibility for paying claims.

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What is a Staff Plan?

A Staff Plan is a type of health insurance plan where the insurer employs its own doctors and other healthcare professionals.

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What happens if a PPO member uses an out-of-network provider?

If a PPO member uses a provider outside the preferred network, they may still receive coverage, but the insurer will pay a reduced amount, and the member is responsible for the difference.

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What is the traditional approach of commercial insurers?

Traditional commercial insurers typically offer reimbursement type contracts, where the insurer pays the policyholder directly for their medical expenses, instead of paying the provider directly.

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What is considered an 'Insurance Transaction'?

An insurance transaction involves negotiation between parties, such as agreeing on terms and conditions of the policy.

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What is a Medical Expense Policy?

A Medical Expense Policy, sometimes called a Regular or Basic Medical Expense Policy, covers inpatient visits and may include additional coverage for office visits, diagnostic tests, ambulance, and maternity benefits.

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What are the key features of a Major Medical Policy?

A Major Medical Policy typically has a high deductible, coinsurance, and a stop-loss limit. It often includes provisions like Carry-Over, Common Accident, and Restoration of Benefits.

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Physical Exam & Autopsy provision

The insurer has the right to request a physical exam or autopsy at their own expense, if allowed by law.

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Unpaid Premiums provision

The insurer can deduct unpaid premiums from a claim.

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Grace period in individual medical expense policies

This period grants a policyholder time to pay premiums after the due date without lapsing the policy.

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Noncancellable policy

A type of policy that cannot be canceled by the insurer but is renewable at the option of the insured, with premiums guaranteed up to age 65.

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Insuring Clause

This clause in a contract outlines the coverage, the amount, the duration, and the perils covered by the policy.

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Preexisting condition

A preexisting condition is a health issue that existed before the policy started. It may affect coverage or premiums.

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Optionally Renewable policy

A policy that can only be renewed at the option of the insurer.

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Guaranteed Renewable policy

A policy that can be renewed without proof of insurability. Premiums may change.

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Study Notes

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Description

Test your knowledge on health insurance concepts, including Medicaid eligibility, HMO plans, and Medicare beneficiaries. This quiz covers key aspects of medical expense policies and insurance coverage conditions. Perfect for anyone looking to deepen their understanding of healthcare systems.

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