Health Insurance Providers Chapter 13

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?

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?

80% (correct)

40%

100%

60%

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?

Skilled nursing facility care Signup and view all the answers

An accident and health policy that provides reimbursement benefits makes them payable to the:

Insured Signup and view all the answers

Which of the following is an example of a third-party administrator?

Outside organization that processes claims for an employer's self-funded group plan Signup and view all the answers

Medicare provides coverage for each of the following EXCEPT:

Custodial care Signup and view all the answers

Paul has a disease unique to the trade in which he was exposed to. Paul has a(n):

Occupational disease Signup and view all the answers

Which of the following services are health maintenance organizations (HMOs) NOT required to provide?

Prescription drugs Signup and view all the answers

Individuals age 65 or older are exclusively eligible for which optional program?

Medicare Part B Signup and view all the answers

Which statement regarding Medicare is true?

Benefits for diagnostic tests and X-rays performed on an outpatient basis are provided by Part B Signup and view all the answers

A medical provider that accepts Medicare Assignment must:

Accept payment based upon a defined Medicare schedule as payment in full Signup and view all the answers

An individual can enroll in a Part C Medicare Advantage Plan at what time?

When becoming eligible for Medicare Signup and view all the answers

Small employers who are sponsored by an insurer to provide group benefits to its employees are called:

MEWA Signup and view all the answers

Which of the following is NOT a characteristic of a preferred provider organization (PPO)?

Primary physicians serve as gatekeepers Signup and view all the answers

Funding for Medicare Part B is partially provided by:

User premiums Signup and view all the answers

After the annual deductible is met, Medicare Part B will pay ___ of the remaining approved charges.

80% Signup and view all the answers

The role of the federal government was expanded when Medicaid was established by allowing the state to:

Receive matching funds to expand public assistance programs Signup and view all the answers

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.

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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.