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Questions and Answers
Maria is a Preferred Provider Organization (PPO) subscriber and received care from an out-of-network provider. What is the likely result?
Maria is a Preferred Provider Organization (PPO) subscriber and received care from an out-of-network provider. What is the likely result?
- Care is covered (correct)
- Care is not covered
- Care is only covered if primary care physician gives a referral
- Care is only covered in a government facility
How much does Medicare Part B pay for physician fees?
How much does Medicare Part B pay for physician fees?
- 80% (correct)
- 40%
- 100%
- 60%
Which of the following is NOT taken into consideration when determining eligibility for Medicare benefits?
Which of the following is NOT taken into consideration when determining eligibility for Medicare benefits?
- Social Security disability
- Income (correct)
- Chronic kidney disease
- Age
Medicare Part A covers what type of care?
Medicare Part A covers what type of care?
An accident and health policy that provides reimbursement benefits makes them payable to the:
An accident and health policy that provides reimbursement benefits makes them payable to the:
Which of the following is an example of a third-party administrator?
Which of the following is an example of a third-party administrator?
Medicare provides coverage for each of the following EXCEPT:
Medicare provides coverage for each of the following EXCEPT:
Paul has a disease unique to the trade in which he was exposed to. Paul has a(n):
Paul has a disease unique to the trade in which he was exposed to. Paul has a(n):
Which of the following services are health maintenance organizations (HMOs) NOT required to provide?
Which of the following services are health maintenance organizations (HMOs) NOT required to provide?
Individuals age 65 or older are exclusively eligible for which optional program?
Individuals age 65 or older are exclusively eligible for which optional program?
Which statement regarding Medicare is true?
Which statement regarding Medicare is true?
A medical provider that accepts Medicare Assignment must:
A medical provider that accepts Medicare Assignment must:
An individual can enroll in a Part C Medicare Advantage Plan at what time?
An individual can enroll in a Part C Medicare Advantage Plan at what time?
Small employers who are sponsored by an insurer to provide group benefits to its employees are called:
Small employers who are sponsored by an insurer to provide group benefits to its employees are called:
Which of the following is NOT a characteristic of a preferred provider organization (PPO)?
Which of the following is NOT a characteristic of a preferred provider organization (PPO)?
Funding for Medicare Part B is partially provided by:
Funding for Medicare Part B is partially provided by:
After the annual deductible is met, Medicare Part B will pay ___ of the remaining approved charges.
After the annual deductible is met, Medicare Part B will pay ___ of the remaining approved charges.
The role of the federal government was expanded when Medicaid was established by allowing the state to:
The role of the federal government was expanded when Medicaid was established by allowing the state to:
Study Notes
Medicare and Health Insurance Basics
- Preferred Provider Organization (PPO): Subscribers can receive care from out-of-network providers, typically with coverage provided.
- Medicare Part B: Covers 80% of physician fees, with the insured responsible for the remaining balance after meeting deductibles.
Medicare Eligibility and Coverage
- Determining Eligibility for Medicare: Chronic kidney disease, age, and Social Security disability are factors; however, income is not considered.
- Medicare Part A Coverage: Includes skilled nursing facility care but not custodial care or prescription drugs.
Insurance Policies and Types
- Accident and Health Policies: Reimbursement benefits are payable to the insured directly, not the provider or facility.
- Third-party Administrators: Outside organizations that process claims for self-funded group plans play a key role in claims management.
Medicare Benefits Limitations
- Exclusions from Coverage: Medicare does not cover custodial care or certain other extended services, emphasizing specific medical services and hospital-related costs.
Occupational Health
- Occupational Disease: Defines conditions unique to a worker's trade, distinguishing it from other disease types.
Health Maintenance Organizations (HMO)
- HMO Services: Not required to provide prescription drug coverage, whereas emergency services, hospitalization, and preventative services are mandated.
Enrollment in Medicare Programs
- Medicare Part B Enrollment: Exclusively available for individuals aged 65 and older, highlighting age as a significant qualification factor.
- Medicare Advantage Plan (Part C): Enrollment is possible when becoming eligible for Medicare.
Characteristics of Insurance Models
- PPO Characteristics: Typically operate on a fee-for-service basis without gatekeepers, providing a broader choice of physicians but may involve higher patient fees.
Medicare Funding
- Funding Sources for Medicare Part B: Primarily derived from user premiums, with additional funding mechanisms in place to ensure service coverage.
Key Medicare Facts
- Medicare's Coverage for Services: After deductibles, Part B pays 80% of approved charges, underlining the importance of understanding out-of-pocket costs for patients.
- Federal Government's Role: Expanded with Medicaid to allow states to access matching funds for public assistance programs, increasing available health resources.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Test your knowledge on Health Insurance Providers with this quiz focused on Chapter 13. The quiz features flashcards that cover essential concepts such as PPO memberships and Medicare benefits. Enhance your understanding of health insurance terminology and coverage details.
