Exam 412757rr – group medical expense benefits


Exam: 412757RR – Group Medical Expense Benefits

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Questions 1 to 20: 

Select the best answer to each question. Note that a question and its answers may be split across a page break, so be sure that you have seen the entire question and all the answers before choosing an answer.

1. Which of the following statements concerning extended-care facility benefits is correct?

A. Benefits are usually provided only if 24-hour-a-day nursing care is needed.

B. Benefits are not contingent upon a prior hospitalization.

C. Benefits usually are provided for domiciliary care for the aged.

D. Benefits usually are provided for inpatient treatment of drug or alcohol abuse.

2. An HMO that contracts solely with two or more independent groups of physicians to provide medical services to its subscribers is called a

A. mixed-model HMO.

B. group-model HMO.

C. network-model HMO.

D. individual practice association.

3. Which of the following statements about second opinions is correct?

A. If the first and second opinion conflict, the patient must make a decision or pay for a third opinion out of pocket.

B. More plans are requiring mandatory second opinions because it has proven to contain costs.

C. Mandatory provisions often apply only to a specified list of procedures.

D. Voluntary provisions require the insured to accept the final opinion or face financial consequences.

4. Which of the following statements concerning the NAIC Small Employer Health Insurance Availability Model Act is correct?

A. Insurance companies can use the same policies in multiple states.

B. If coverage is made available to employees, it must also be made available to their dependents.

C. All providers of medical expense coverage are required to offer coverage to small employers.

D. Pre-existing conditions provisions are not allowed.

5. The use of health savings accounts and other self-directed medical expense plans typically involve the use of medical expense policies.

A. Blue Cross and Blue Shield

B. self-insured

C. high-deductible

D. traditional

6. When Blue Cross first began, it was in the business of providing coverage for

A. physician care for the financially needy.

B. physician care for the elderly.

C. hospitalization.

D. prescriptions.

7. State reactions to managed care backlash include prohibitions against which of the following?

A. Point-of-service options

B. Direct access to specialists

C. Any-willing-provider laws

D. Provider gag clauses

8. All the following expenses are often subject to internal limitations under major medical policies except

A. diagnostic X-rays and laboratory services.

B. home healthcare benefits.

C. treatment for mental and nervous disorders.

D. hospital room and board.

9. The medical expense insurance-like organizations that eventually came to be called Blue Cross plans were initially run by

A. charity organizations.

B. employers.

C. physicians.

D. hospitals.

10. Jim and Betty are married with one child, and both are employed by the same company. Jim, who was born on February 9, 1968, has been with the company for 10 years. Betty, who was born on May 12, 1965, has been with the company for 8 years. Who is the primary provider of health care coverage for the child?

A. Betty, because she’s older than Jim

B. Jim, because of his date of birth

C.Both Betty and Jim, because they have the same insurance

D. Jim, because he’s been with the company longer than Betty

11. Mary goes to the doctor and pays for her visit. When she gets home, she must fill out a form and submit it to the insurance company so she can be reimbursed. What type of insurance does she most likely have?


B. The Blues

C. Indemnity


12. Which of the following would typically be covered under home healthcare benefits?

A. 24-hour nursing care

B. Prescription drugs

C. Physical therapy

D. Diagnostic testing

13. Which of the following statements concerning the Mental Health Parity Act is correct?

A. It requires employers to make benefits available for mental illness.

B. The provisions of the act only apply to employers with more than 50 employees.

C. It requires alcoholism and drug addiction to be treated like any other mental illness.

D. It prohibits different cost-sharing provisions for mental health benefits and other medical and surgical benefits.

14. Which of the following statements concerning basic medical expense benefits is correct?

A. Hospital expense coverage usually provides coverage for emergency room treatment of accidental injuries at any time following an accident.

B. Surgical expense coverage usually provides benefits for surgery in a hospital only.

C. Hospital expense coverage usually expresses room-and-board benefits as the full cost of semiprivate accommodations.

D. Physicians’ visits expense coverage must always include out-of-hospital visits.

15. A benefit that does not try to cure a person’s ailments, but rather attempts to make a patient comfortable in his or her last days or weeks before death, is called

A. home health care.

B. terminal care.

C. extended care.

D. hospice.

16. Which of the following statements concerning point-of-service plans is correct?

A. The term point-of-service implies a lesser degree of managed care than is found in most PPOs.

B. They are hybrid arrangements that combine aspects of an HMO with a PPO.

C. A member of a point-of-service plan can never go outside the plan’s network without informing the plan.

D. They prohibit treatment outside an exclusive-provider network unless the network does not contain an appropriate specialist.

17. Company X must make sure that it provides HMO coverage as an option in its benefit-selection process. What act would require Company X to do this?

A. Financial Services Modernization Act

B. Health Insurance Portability and Accountability Act

C. Americans with Disabilities Act

D. Health Maintenance Organization Act

18. Which of the following types of medical expense plans has the highest degree of managed care?

A. Point-of-service plans

B. Independent practice association HMOs

C. Closed-panel HMOs

D. Preferred provider organizations

19. A benefit plan that provides a less expensive choice for treatment is often a smart way to reduce costs. An example of this type of plan is

A. implementing maximum benefits.

B. allowing the use of birthing centers.

C. allowing longer hospital stays.

D. requiring higher deductibles.

20. Which of the following statements concerning multiple-option plans is correct?

A. Because the plans are subject to experience rating, costs may be higher.

B. Non-federally qualified HMOs are never used in multiple-option plans.

C. They may allow experience rating of an employer’s entire medical expense plan, including HMO coverage.

D. They increase administrative complexity if an employer offers more than one type of medical expense coverage.

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