Question 1

Most health insurers ask that patients pay a portion (or percentage)of the charge for professional services.This charge is commonly referred to as:

Accepted Answer

Coinsurance is the portion of healthcare expenses that the patient is responsible for paying, usually expressed as a percentage. It is a common feature of health insurance plans and is in addition to any deductibles that must be met before insurance coverage begins.

Question 2

People who are covered under managed care plans are commonly referred to as:

Accepted Answer

Enrollees are individuals who are covered under managed care plans. Policyholders usually refer to those who have purchased insurance policies. Charter members and covered entities are not commonly used terms in the context of managed care plans.

Question 3

A special tax shelter set up for the purpose of paying medical bills is a/an:

Accepted Answer

A medical savings account (MSA) is a tax-sheltered account designed specifically to help individuals save money for eligible medical expenses. It allows individuals to contribute pre-tax dollars into the account and withdraw the funds tax-free to pay for qualified medical expenses. MSAs are sometimes referred to as Health Savings Accounts (HSAs) or Flexible Spending Accounts (FSAs).

Question 4

The traditional kind of health insurance wherein patients can choose any provider or hospital they wish and change physicians at will is:

Accepted Answer

Indemnity and fee-for-service health insurance plans allow patients the freedom to choose any provider or hospital and change physicians at will, without needing referrals or pre-approvals.

Question 5

The dollar amount that a patient must pay each year before his or her insurance benefits begin is called a/an:

Accepted Answer

The dollar amount that a patient must pay each year before his or her insurance benefits begin is called a deductible. A copayment is a set amount that a patient pays for a specific medical service or medication, while reimbursement refers to the amount paid back to the patient or healthcare provider by the insurance company for services rendered. A dividend is a distribution of profits by a company to its shareholders.

Question 6

A family physician,internist,obstetrician-gynecologist,or pediatrician who is usually the patient's first contact for healthcare defines a/an:

Accepted Answer

A primary care physician is the first point of contact for healthcare for most patients, and includes family physicians, internists, obstetrician-gynecologists, and pediatricians. They provide preventive care, diagnose and treat common illnesses, and refer patients to specialists when necessary. Participating provider and principal provider are not commonly used terms in healthcare, and initial provider does not accurately describe the role of a primary care physician.

Question 7

The monthly (or periodic)fee paid for health insurance is commonly called a:

Accepted Answer

The term used for the monthly or periodic fee paid for health insurance is premium. A stipend refers to a fixed, regular payment, usually a salary or allowance, while penalty refers to a punishment or fine for breaking a rule or law. Disbursement refers to the act of paying out money, but it is not specific to health insurance.

Question 8

An insurance contract made with a business entity that covers its employees under a single policy is called a/an:

Accepted Answer

A group contract is an insurance policy that provides coverage to a group of people, typically employees of a business entity, under a single policy. The policyholder is the employer, while the insured are the employees. This type of policy is often more cost-effective and easier to manage compared to individual policies for each employee. Therefore, the correct answer is A) group contract.

Question 9

A _____ provider is one who contracts with the insurer,agreeing to abide by certain rules and regulations of that carrier.

Accepted Answer

A participating provider is one who has agreed to work with the insurer and adhere to their guidelines and regulations. This usually means that the provider will receive higher levels of reimbursement from the insurer and may be more attractive to patients who are covered by that particular carrier. In contrast, a nonparticipating provider is one who does not have any formal relationship with the insurer and may not receive the same level of reimbursement. Managed healthcare and fee-for-service are related concepts but not directly relevant to this question.

Question 10

A network of doctors and hospitals that shares responsibility for managing healthcare needs of a minimum of 5000 Medicare beneficiaries for at least 3 years.

Accepted Answer

An Accountable Care Organization is a network of doctors and hospitals that share responsibility for managing the healthcare needs of a minimum of 5000 Medicare beneficiaries for at least 3 years. The goal of an ACO is to improve the quality of care and reduce healthcare costs by keeping patients healthy and out of the hospital.

Question 11

Medical illnesses or injuries that a patient has before the purchase of a health insurance policy are called:

Accepted Answer

Preexisting conditions are medical illnesses or injuries that the patient had before purchasing a health insurance policy. Insurers often exclude coverage for preexisting conditions or charge higher premiums for individuals with such conditions. This is done to prevent adverse selection, where individuals only purchase insurance once they become ill, which raises costs for insurers and other policyholders.

Question 12

When an individual is eligible for coverage under two different health insurance policies,____________________ limits the total benefits an insured individual can receive from both plans to not more than 100% of the allowable expenses.

Accepted Answer

When an individual is eligible for coverage under two different health insurance policies, coordination of benefits (COB) limits the total benefits an insured individual can receive from both plans to not more than 100% of the allowable expenses. This ensures that the insured does not receive more than the total cost of their medical expenses, preventing overpayment and fraud. COB is commonly used when both spouses have employer-sponsored health insurance plans.

Question 13

A health insurance model intended to create a more organized and competitive market by offering consumers plan choices with common rules as to how the plan is offered,its cost,etc.defines a/an:

Accepted Answer

A health insurance exchange is a marketplace where consumers can compare and purchase health insurance plans from competing insurance providers. The exchange sets standards for the plans offered, such as coverage requirements and pricing transparency, in order to promote fair competition and give consumers more choice and control over their insurance options. This model was implemented as part of the Affordable Care Act in the United States.

Question 14

The type of insurance that covers a broad range of services,including nursing home care,assisted living facilities,certain types of home healthcare,and adult day care.

Accepted Answer

Long-term care insurance is the type of insurance that covers a broad range of services, including nursing home care, assisted living facilities, certain types of home healthcare, and adult day care. It is specially designed to provide coverage for long-term care services not covered by traditional health insurance policies.

Question 15

Most third-party payers do not pay for medical services that are:

Accepted Answer

Most third-party payers do not pay for medical services that are not medically necessary. This means that if a medical service or procedure is not deemed necessary for the patient's health and wellbeing, it may not be covered by insurance. This is done to prevent unnecessary medical costs and to ensure that resources are being used effectively.

Question 16

When an individual purchases a healthcare policy from a commercial insurer,he or she is said to have a/an:

Accepted Answer

An individual who purchases a healthcare policy from a commercial insurer is said to have an individual policy, which is a type of private health insurance coverage. Choice C is not correct because a managed care plan is a type of health insurance plan that focuses on cost-effective healthcare delivery by establishing a network of healthcare providers who are incentivized to provide high-quality care at a lower cost.

Question 17

Fee-for-service health insurance policies generally limit what a patient must pay on their own,which is referred to as the:

Accepted Answer

Fee-for-service health insurance policies have an out-of-pocket maximum limit that determines the maximum amount a patient has to pay before their health insurance plan covers the rest of their healthcare expenses. This limit typically includes deductibles, co-payments, and coinsurance expenses. Once the out-of-pocket maximum is reached, the insurance company will cover all additional expenses for the remainder of the policy year.

Question 18

Health insurance payments are sometimes based on what is referred to as:

Accepted Answer

Health insurance payments are often based on UCR (Usual, Customary, and Reasonable) rates, which are the standard rates of medical services in a particular geographical area. These rates are determined by insurance companies based on information from healthcare providers and are used to set the amount that the insurer will pay for a particular service or treatment.

Question 19

The level of health plan which is most like the former "basic" coverage is called the:

Accepted Answer

The bronze plan is the level of health plan that is most like the former "basic" coverage. It has the lowest monthly premiums but also the highest out-of-pocket costs. This plan may be a good choice for those who are generally healthy and don't anticipate needing a lot of medical care, but still want some level of protection.

Question 20

The form that is most commonly used today for insurance claims submitted on paper is the:

Accepted Answer

The CMS-1500 is the standard form used for submitting healthcare insurance claims on paper. The UB-04 form is used for institutional claims for hospitals and other healthcare facilities. The HCFA-1490 is an old form that has been replaced by the CMS-1500. The HCPCS 1090 is not a form, but a code used for healthcare procedures and services.

Quiz 4: Types and Sources of Health Insurance

Most health insurers ask that patients pay a portion (or percentage) of the charge for professional services.This charge is commonly referred to as: