Health Insurance MCQs

The Albuquerque HMOâ€™s contracting physicians are paid employees working on the staff of the HMO, operating in a clinic setting at the HMOâ�...

Staff model HMO
Network model HMO
Group model HMO
Individual Practice Association Model HMO

Star HMO contracts with 14 medical groups to increase accessibility to providers as a convenience for subscribers. Each of the medical groups is pai...

Staff model HMO
Network model HMO
Group model HMO
Individual Practice Association Model HMO

The Providerâ€™s Choice HMO was started by a group of individual physicians who each operate out of their own offices. The physicians are paid ...

Staff model HMO
Network model HMO
Group model HMO
Individual Practice Association Model HMO

Gwynethâ€™s HMO requires that she receive health care services from a specified, limited number of health care providers chosen by the HMO. Gwy...

Open-panel
Closed-panel
Choice-panel
Guarded-panel

All of the following are examples of managed care plans except

Health maintenance organizations
Preferred provider organizations
Indemnity arrangements
Point-of-service plans

A method of payment in which a provider is paid a specific fee monthly for each subscriber is known as

Indemnity
Fee-for-service
Managed care
Capitation

Calvin is hit by a car while traveling out of state. When the bill for his emergency services arrives, Calvinâ€™s HMO will probably

Pay for the services, even though they were incurred out-of-network, because emergency coverage is a basic health care service.
Deny the claim, because the services were out of network.
Pay the claim only if the HMO had an affiliation agreement with the facility where the services were provided.
Pay the claim if the HMO had an affiliation agreement with the facility where the services were provided, or there is no affiliated facility within 50 miles.

The Gargantuan Garage company funds its own claims, but it uses another company to make sure the plan is run correctly, acting as a liaison between ...

Cafeteria plan
Health Maintenance Organization
Multiple employer trust
Third-party administrator

Julia has a policy that will pay any expenses that she incurs due to inhospital medical treatment, as well as some of the expenses she incurs on an o...

Disability income policy
Medical expense insurance policy
Long-term care policy
Hospital income insurance policy

George has a policy that will provide him an income if he is disabled from illness or injury and recuperating at home. George probably has a

Disability income policy
Medical expense insurance policy
Long-term care policy
Hospital income insurance policy

When a health insurance policy becomes effective, unless it is canceled, it will stay in force

For 1 year
For 6 months
The length of the term
Indefinitely

Legally, the policy is considered delivered in all of the following situations except:

When the policy is approved by the company
When the policy is mailed to the policyowner
When the policy is turned over to the policyowner
When the policy is turned over to someone acting on behalf of the policyowner

An insurer might require personal delivery

To ensure the policy goes to the right person
For verification of the continued good health of the insured at the time of delivery
To ensure the correct policy is delivered
To verify information listed on the application

No loss-no gain legislation

Requires a replacing policy to have exactly the same premium as the policy it replaces
Requires a replacing policy to have exactly the same limits of coverage as the policy it replaces
Requires a replacing policy to continue to pay claims ongoing under the policy it replaces
Requires a replacing policy to continue to use the same producer to manage the policy as the policy it replaces

A statement that assures benefits provided under the old policy will continue under the new policy is

A transfer of benefits statement
A continuation of benefits statement
A preexisting conditions coverage statement
A replacement statement

Restrictions applying to the replacement of Medicare supplement policies

Are often less restrictive than regulations applying to the replacement of other policies
Are generally the same as regulations applying to the replacement of other policies
Are often more restrictive than regulations applying to the replacement of other policies
Are prohibited entirely by federal law

Ally pays for her health insurance monthly. Her identical twin Georgia has the same policy, but pays annually. Which of them probably pays more for ...

Ally probably pays more.
Georgia probably pays more.
They probably pay the same.
It is not possible to determine from the information provided.

Health insurance coverage never applies until

The policy is delivered.
An underwriting decision is made.
The application is reviewed by underwriting.
The insured has paid for the policy

The grace period varies according to

Premium payment frequency
Premium payment amount
Method of premium payment
Type of policy

Mike allows his policy to lapse and then applies for reinstatement using the companyâ€™s required application. The company does not inform Mike...

Not until the insurer notifies him that it has been reinstated
As soon as the application has been submitted
After 45 days
After 90 days

The maximum time during which suit can be filed is

1 year after written proof of loss is furnished
2 years after written proof of loss is furnished
3 years after written proof of loss is furnished
4 years after written proof of loss is furnished

Which of the following is not a required provision under the Uniform Provisions Model Act?

Grace period
Change of occupation
Time of payment of claims
Proof of loss

Which of the following is an optional provision under the Uniform Provisions Model Act?

Cancellation
Physical examination and autopsy
Legal actions
Reinstatement

Cindy has a claim for $2,000, and a past due premium of $200. The insurer will

Refuse to pay the claim until the past due premium is paid.
Pay the claim minus the past due premium.
Pay the claim and forgive the past due premium
Pay the claim and bill Cindy for the past due premium.

If Lois cancels her health insurance policy, the insurer will

Issue a pro rata refund of all of the unearned premium.
Issue a pro rata refund of most of the unearned premium.
Issue a short-rate refund of all of the unearned premium.
Issue a short-rate refund of most of the unearned premium.

Carmen gets her health insurance policy on May 1, and on May 3 she decides she doesnâ€™t want it and returns it to the company. On May 6, she i...

Will pay any resulting claim, because she was injured within the 10-day free-look period.
Will pay any resulting claim only if the premium has not yet been returned to Carmen.
Will pay any resulting claim minus the amount of the returned premium.
Will only return any premium Carmen has paid and not any resulting claim.

CeeCeeâ€™s policy is guaranteed renewable. Which of the following may the insurer not do?

Refuse to renew the policy if CeeCee fails to pay the premium.
Increase the premiums on all members of CeeCeeâ€™s class.
Increase the premiums on CeeCeeâ€™s policy only.
Refuse to renew the policy after CeeCee reaches a specified age.

George has a noncancelable policy. Which of the following may the insurer do?

Cancel the policy if George fails to pay premiums.
Increase the premiums on all members of Georgeâ€™s class.
Increase the premiums on Georgeâ€™s policy only.
Cancel the policy if the insurer chooses to no longer do business in Georgeâ€™s state.

The longer the benefit period

The higher the policyâ€™s premium will be
The lower the policyâ€™s premium will be
The higher the policyâ€™s benefits will be
The lower the policyâ€™s benefits will be

Which definition of total disability is more favorable to the insured?

Own occupation.
Any occupation.
They are the same in terms of benefits to the insured.
There is no way to determine from the information provided

Which of the following statements is not true about partial disability?

The person is not able to perform every duty of his or her prior occupation.
The person is able to perform one or more important duties of his or her occupation.
Sickness disability is more likely than accident disability to be partial.
An insured might receive both total and partial disability benefits as the result of a single accident.

Brandon injures his back working at a warehouse. Six months later, he is well enough to go back to work lifting boxes. Two weeks into working, however...

Redundant disability
Residual disability
Recurrent disability
Reduced disability

Lee is helping a friend move his pool table when he strains his back, causing a disability. The insurer declines coverage, saying the injury was not...

An accidental bodily injury definition of accidental
An accidental means definition of accidental
A confining definition of accidental
A nonconfining definition of accidental

Most often, LTD policies provide benefits

For 2 years
For 5 years
To age 60
To age 65

Which of the following statements is not true regarding the future increase option rider?

The rate for additional coverage will be at the insuredâ€™s attained age at the time of purchase
The rider guarantees the ability to increase coverage to a predetermined limit, regardless of change in the insuredâ€™s income.
The rider generally limits the number of option dates on which the insured may purchase additional coverage.
The rider usually limits the amount of additional coverage available at each option date.

Full disability benefits will generally be paid for the lifetime of the insured if total disability due to sickness begins at age

45 or earlier
50 or earlier
55 or earlier
65 or earlier

Which of the following statements is true regarding social security disability benefits?

For benefits to be paid, the disability must be permanent and expected to end in death.
For benefits to be paid, the disability must prevent the individual from being able to perform any substantial gainful work existing in the national economy.
Most of the people who apply for disability under social security are able to get benefits.
Social security provides a fairly liberal definition of total disability to keep individuals able to spend and support the national economy

The benefit that pays the regular total disability benefit during the elimination period when the insured is hospitalized is known as the

Hospital confinement rider
Rehabilitation benefit
Nondisabling injury rider
Offset rider

Carmen falls and breaks her leg, incurring $2,000 in medical expenses. Her policy pays the entire amount. Carmen has a

Hospital expense policy
Surgical expense policy
Medical expense policy
Policy with first dollar coverage

A combination of basic medical expense coverage and major medical expense coverage is

A basic medical expense policy
A major medical expense policy
A comprehensive medical expense policy
A supplemental medical expense policy

Maternity benefits must be provided on the same basis as non maternity benefits

In all cases
Only if the insurer chooses to do so
If the policy covers an employee group of 15 or more people
If the policy provides disability income coverage

Among individual policies that include coverage for mental infirmities, the benefit will generally be

Lower than the benefit for physical infirmities
Higher than the benefit for physical infirmities
Unlimited
The same as the benefit for physical infirmities

A hospice

Treats diseases only, not accident-related medical issues
Controls pain and suffering and treats illness
Alleviates pain and suffering among terminally ill patients until their death, but does not attempt to cure
Works with medical professionals when they become ill, to provide treatment in a private setting away from lay patients

The dollar limit beyond which the insurer no longer participates in payment of expenses is the

Deductible
Coinsurance
Stop-loss limit
Maximum benefit

The expenses that must be incurred before major medical benefits begin to be paid is the

Deductible
Coinsurance
Stop-loss limit
Maximum benefit

A deductible that runs between the first dollar coverage of a basic policy and the comprehensive coverage of a supplemental policy is known as a

Stop-loss deductible
Capitated deductible
Corridor deductible
Limited deductible

Which of the following would be most likely to be covered under a medical expense policy?

Gertrude steps on a rusty nail and requires a tetanus shot.
Carmelita decides to get a flu shot this year.
Gary goes to the doctor each year for an annual checkup.
Earl requires some help getting dressed in the morning.

Comprehensive dental policies

Limit benefits to specified maximums per procedure
Work much the same way as comprehensive medical expense coverage
Never require deductibles
Seldom require coinsurance

Which of the following is not likely to be considered nonroutine dental care?

Treatment of the soft tissue substance located in the center of each tooth
Microscopic analysis of tissue biopsy material for diagnosis of oral diseases, including oral cancer
Annual checkups and cleaning of teeth, including x-rays to check the health of the teeth
Repairing or restoring dental work that has been damaged in some way

For nonroutine treatments, a comprehensive dental policy generally pays

The full amount
A percentage of the reasonable and customary charges from the first dollar
A percentage of the reasonable and customary charges after a deductible
Nothing

The main difference between a prepaid dental plan and a comprehensive dental plan is that

Comprehensive dental plans pay based on reasonable and customary charges, and prepaid dental plans pay on a capitation basis.
Comprehensive dental plans pay on a capitation basis, and prepaid dental plans pay based on reasonable and customary charges.
Comprehensive dental plans cover routine services, but prepaid dental plans do not.
Comprehensive dental plans do not cover routine services that are covered by prepaid dental plans

Hospital indemnity insurance pays

Medical costs only while the insured is confined to the hospital
Supplemental costs, such as television or phone charges, while the insured is confined to the hospital
An income for each day the insured is confined to the hospital
An income for each month the insured spends partially confined to the hospital

Vision care insurance is generally needed to cover all of the following except

Injury to the eye
Eye examinations
Costs of contact lenses
Costs of prescription lenses

Prescription drug policies generally exclude

Any narcotic substance
Any drugs not covered by other programs
Experimental drugs
Drugs for ongoing medical conditions

Credit health insurance covers

A creditor
A debtor
Either a creditor or a debtor
Neither a creditor nor a debtor

The amount of coverage available under a credit insurance policy is generally limited to

The total amount of indebtedness at any given point
The total amount of the loan covered
The amount the policy is written for
No limit

The creditor must notify the debtor that he or she may be covered by the group insurance plan

Only if the debtor is to be charged the full premium for the insurance
If the debtor is to be charged more than half the premium amount
Even if the creditor pays the full cost of the coverage
If the creditor chooses to make the disclosure

A type of policy covering doctor visits while the insured is in the hospital is

A basic medical expense policy
A major medical expense policy
A comprehensive medical expense policy
A supplemental medical expense policy

Which of the following is not part of the qualification process for legal dependency?

Relationship to the insured
Residency in the home
Eligibility for insurance
Listing on the insuredâ€™s tax return as a dependent

When both parents have employer-provided group coverage, the children are covered under

The fatherâ€™s plan
The motherâ€™s plan
The plan of the parent whose birthday falls closest to the childâ€™s birthday
The plan of the parent whose birthday falls closest to the start of the calendar year

Under the coordination of benefits rule, the primary company pays

If there is no other coverage
As if there were no other coverage
Whatever the other coverage does not pay, up to the policy limits
Only if the other coverage refuses the claim

Carla enrolls in group insurance when she is eligible under her employerâ€™s plan. Because of an administrative error, her enrollment form is n...

Deny the claim, because it has no record of her policy.
Force the employer to pay the claim, because it was the employerâ€™s error.
Pay the claim only if the insurer is proven to have made an error.
Accept the enrollment form and all of the past due premium and pay the medical claim.

What is the federal law that requires employers with more than 20 employees to include in their group insurance plan a continuation of benefits prov...

COBRA
OBRA
ERISA
TEFRA

What is the federal law that extends the minimum continuation of coverage period from 18â€“29 months for qualified beneficiaries disabled at the...

COBRA
OBRA
ERISA
TEFRA

Which of the following provisions is not a part of HIPAA?

Employers must make full health care coverage available immediately to newly hired employees who were previously covered for at least 18 months.
New mothers and their babies must be allowed to stay in the hospital for at least 48 hours following a regular delivery.
Small employers may not be denied group health insurance coverage because one or more employees is in poor health.
Annual limits and lifetime spending limits may no longer apply to mental health coverage

Which of the following is considered a disqualifying event under COBRA?

The employer ceases to maintain any group health plan.
The employee is no longer eligible for the group health plan due to a change in the covered classes.
The employee voluntarily leaves employment with the employer.
The employeeâ€™s employment is terminated by the employer.

Under OBRA, an employer may terminate COBRA coverage because of coverage under another health plan

As soon as the coverage is in force
As long as the other health plan does not limit benefits for the insuredâ€™s preexisting conditions
As long as the other health plan limits benefits for the insuredâ€™s preexisting conditions
Only if the premiums for the new plan are paid entirely by the insuredâ€™s new employer

The Age Discrimination in Employment Act applies to employees who are

40 or older
45 or older
50 or older
55 or older

Carla is 67 and eligible for social security and medicare. When she comes out of retirement to work at a large corporation which provides health ben...

Her private benefits become secondary to medicare benefits.
Her medicare benefits become secondary to her private benefits.
The employer is not required to offer her private benefits.
She will cease to be eligible for medicare benefits.

Medicare Part A covers all of the following except

Charges for a private room
Skilled nursing facility care
Home health care
Hospice care

For each benefit period, medicare will pay the full cost of up to

30 days of hospital care
60 days of hospital care
90 days of hospital care
365 days of hospital care

Medicare will pay the entire cost for skilled nursing facility care for the first

20 days
80 days
100 days
0 days

Medicare Part A provides coverage for all of the following kinds of care except

Private duty nursing
Skilled nursing facility care
Home health care
Hospice care

Medicare Part B provides coverage for all of the following kinds of care except

Skilled nursing facility care not covered by Part A
Doctorâ€™s services
Home health care not covered by Part A
Outpatient medical services and supplies

Which of the following statements about medicare supplement plans is false?

Benefits must automatically change to coincide with changes in medicare deductibles and copayments.
Losses resulting from sickness may not be treated differently than losses resulting from accidents.
The definition of accident may employ an accidental means test.
Policies must be at least guaranteed renewable

In order to be compensable as interpreted in workers compensation law, an injury must meet all of the following criteria except

It must be accidental.
It must arise out of the individualâ€™s employment.
It must arise in the course of the individualâ€™s employment.
It must be unforeseeable

Medicare supplement policies are also known as

Medicare policies
Medigap policies
Medicaid policies
Medicare+Choice policies

Early long-term care policies were

More restrictive than current policies
Less restrictive than current policies
The same as current policies
Prohibited by law

Which of the following individuals is most likely to be rated a substandard risk under an LTC policy?

Gerald, who lives alone and has no trouble taking care of himself, but who has been diagnosed with an inoperable brain aneurysm that, if it bursts, would almost certainly kill him immediately
Ken, who is on medication to bring down his blood pressure, but who gets around and takes care of himself easily
Brenda, whose diabetes is under control
Garrison, who has been diagnosed with early-stage Alzheimerâ€™s disease

Which of the following is the type of care most people will require at some time during their later years?

Inpatient hospital care
Skilled nursing care
Custodial care
Intermediate care

Virtually all of the current LTC policies are guaranteed renewable. This means that

The insurer cannot cancel the policy but does reserve the right to increase policy premiums on specified classes of policies
The insurer cannot cancel the policy but does reserve the right to increase policy premiums on individual policies.
The insurer cannot cancel the policy or increase policy premiums on specified classes of policies.
The insurer cannot cancel the policy or increase policy premiums on individual policies.

When waiver of premium applies

The premium is waived immediately upon disability.
The premium payment is suspended permanently after it is invoked.
The premium payment generally resumes when care ceases.
The premium payment is waived only if disability is considered permanent and total.

Typically, the expenses incurred in a hospice will be

Surgical and room and board
Room and board and physical therapy
Surgical and physical therapy
Room and board and medication for pain

The elimination period may be thought of as

A dollar amount deductible
A time deductible
A dollar amount copayment
A time copayment

Which of the following is not considered an activity of daily living for the purposes of qualifying a person for LTC benefits?

Transferring
Dressing
Bathing
Working

Nursing home care is generally covered by

Medicare
Medicare supplements
Long-term care policies
All of the above

Which of the following individuals would be least likely to be a good candidate for an LTC policy?

George, whose law practice has allowed him to fund a generous retirement fund for himself and his wife
Nina, a single mother whose financial struggles raising her children have left her with few assets and no independent retirement savings
Carla, whose 25 years of civil service have provided a generous retirement, but who worries about the legacy she will leave her children
Darrell, whose inherited estate has provided him with over $6 million in net worth

Medicare Part A hospital insurance is primarily funded by

General tax revenue
Premiums from beneficiaries
State government taxes
Social security payroll taxes

Social security taxes are paid by employees with

Pre-tax dollars
Tax-deductible dollars
After-tax dollars
Tax-deferred dollars

Premiums for individually owned health policies may be deductible if the taxpayerâ€™s medical expenses exceed

5% of his or her adjusted gross income during the taxable year
5% of his or her adjusted net income during the taxable year
7.5% of his or her adjusted gross income during the taxable year
7.5% of his or her adjusted net income during the taxable year

The premiums paid by a company for group health for its employees are

Not tax-deductible to either the company or the business
Tax-deductible by the company and not considered taxable income to the employees
Tax-deductible by the company and considered taxable income to the employees
Tax-deductible to the employees and the company

Benefits paid by individually owned accident, health, disability, or longterm care policies generally are

Received income taxâ€“free by the taxpayer, provided benefits do not exceed actual expenses
Received income taxâ€“free by the taxpayer even if benefits exceed actual expenses
Received partially tax-free by the taxpayer, provided benefits do not exceed actual expenses
Taxed on receipt by the taxpayer

Qualified group long-term care coverage

Is deductible by both the company and the employee
Is not deductible by either the company or the employee
Is deductible by the company but not the employee
Is deductible by the employee but not the company

Individual disability insurance premiums

Are deductible to the insured, and the benefits are received tax-free
Are not deductible to the insured, but the benefits are received tax-free
Are deductible to the insured, but the benefits are taxed
Are not deductible to the insured, and the benefits are taxed

An individual who is considered chronically ill must be recertified as such

Every month
Every 6 months
Annually
Every 2 years

Blue Cross and Blue Shield are

Health maintenance organizations
Prepaid health care service organizations
Administrative service organizations
Preferred provider organizations

In the administration of a group health insurance plan, if there is a clerical error concerning the information about an insured, that personâ€™...

Could be reduced
Could be delayed
Could be terminated
Will not be affected

For employer-paid (noncontributory) group health insurance, the percentage of eligible group members that must be covered is

50%
65%
75%
100%

One of the reasons why many group disability insurance policies are written on a nonoccupational basis is that

Occupational coverage is too expensive.
Health insurance can no longer be written on an occupational basis.
Occupational coverage is provided by workers compensation.
Few occupational risks exist because of health and safety regulations

A disability that prevents a person from performing one or more of the regular duties of that personâ€™s job and that is a condition that will l...

Permanent partial disability
Permanent total disability
Temporary partial disability
Temporary total disability

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Health Insurance MCQs