certificate
The capital amount of a AD&D rider attached to a life insurance policy pays:
0% of benefit
The principal sum of a AD&D rider attached to a life insurance policy pays:
100% of the benefit
How long must a person be disabled to receive social security disability benefits?
12 mo
Following hospitalization because of an accident, Bill was confined in a skilled nursing facility. Medicare will pay full benefits in this facility for how many days?
20 days
In a nonscheduled plan, the INSURED will be expected to pay what portion of the fees for basic services?
20%
If an insurer pays compensation to an agent for the sale of a Medicare supplement policy, the first-year commission CANNOT exceed what percentage of the renewal commission for servicing the policy in the second policy year?
200%
To qualify as a small employer, a business must have employed no more than
50
In a nonscheduled plan, the insurer will be expected to pay what portion of the fees for major services?
50%
If the insurer failed to pay a claim within the required period of time, all overdue payments will be charged an annual interest of
7.5%
How many eligible employees must be included in a contributory plan?
75%
What are the CE requirements each renewal period for agents who market long-term care insurance policies?
8 hours of classroom
In disability income insurance, if an insured is considered disabled if they cannot perform any job they are suited for by prior education, training, or experience, they fall under what definition of total disability?
ANY OCCUPATION
If an insured misstated his age on an application for health insurance, the insurance company has the right to
Adjust
What disease must an LTC policy cover?
Alzheimer's disease
The Time Limit on Certain Defenses provision is the same as
Incontestability Provision - 2 years
Coinsurance: what does the insured pay and what does the insurer pay?
Insurer pays 80%, insured pays 20%
The type of dental plan which is incorporated into a major medical expense plan is a/an
Integrated dental plan
Which type of health policy covers medical and hospital expenses, has deductibles, coinsurance, and high maximum limits?
Major Medical Insurance (Indemnity Plans)
What two provisions are required in an LTC policy?
Must be guarantee renewable Must offer inflation protection
Man loses one arm and suffers temporary blindness from accident. To what extent will he receive Presumptive Disability benefits?
No benefits - only 1 limb, temporary blindness
own/any occupation is a more liberal definition and therefore provides a better benefit for the insured
OWN
Which factor is considered most important to the underwriting decision for health coverage than for most of the other forms of insurance?
Occupation
What are the terms used to define the amount of benefit paid in the disability policy that contains an accidental and dismemberment rider?
Principal and capital sum
A warranty under which certain things will be done or not done after the policy takes effect is a
Promissory Warranty
Which of the following terms refers to the coverage of an injury or illness when it is considered a continuation of a prior period of disability?
Recurrent (3-6 mo)
The Wisconsin Health Insurance Risk Sharing Plan is a state administered program that provides health insurance for
Wisconsin residents who are unable to obtain health insurance coverage in the private marketplace due to physical or mental impairments
If a LTC policy contains a return of premium feature, and the insured dies, the insurer will return
a certain percentage of the premiums paid
Which of the following standards is used to determine premium rates under the Affordable Care Act (ACA)?
Family Composition
What term means any dissatisfaction with the provision or claim practice of an insurer expressed in writing to the insurer?
Grievance
Which organization provides benefits in the form of services rather than in the form of reimbursement?
HMO's
Which provides care on a prepaid basis: HMO's or PPO's?
HMO's
Who sells Medigap policies?
HMO's and private insurers
Describe the taxation of contributions to a HSA by an employer
Are not included in their taxable income
HMO's operate on what basis?
Capitation - a payment arrangement that pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care
Which RIDER helps protect against inflation?
Cost of Living Adjustment Rider (COLA)
What is the purpose of Medigap policies?
Designed to fill the gap in coverage caused by Medicare's deductibles, copayment requirements, and benefit periods
When can an employee join a group health plan without providing evidence of insurability
During open enrollment (30 days)
Which act ensures that employees receive the pension and other benefits promised by their employers?
ERISA
Which has coinsurance and deductibles: scheduled, or nonscheduled
nonscheduled
The part of Medicare that helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care and hospice care, is known as
part a
According to the general statues and rules for insurance contracts issued in this state, who should receive notice of right to file a complaint?
policyholders and insureds
A medical insurance plan in which the health care provider is paid a regular fixed amount for providing care to the insured and does not receive additional amounts of compensation dependent upon the procedure performed is called
pre-paid
In Medicare prescription drug plans, step therapy refers to
prior authorization
Define Presumptive disability
total loss of sight, speech, hearing, or the use of any two limbs
Crowns would be covered under what type of dental care?
Restorative
How many credits does someone who is FULLY insured under Disability benefits need to have?
40 Credits
If a person has a Medigap policy, and later becomes eligible for Medicaid, benefits and premiums may be suspended for how many years while Medicaid coverage is in force?
2 years
How long is the benefit period in LTC policies?
2-5 years, some offering lifetime of coverage
Within how many days of the original hearing and final issuance of an order (regarding an order issued by the Commissioner) may an aggrieved person request a re-hearing?
20
What is the limit of the "own" definition of occupation
24 months
An insured has Medicare Part D coverage. Upon reaching the initial benefit limit, what percentage of the prescription drug cost is the insured responsible for paying?
25%
How long must an agent keep records of disability policy replacements?
3 years
How long is the Free Look Period in LTC policies?
30 days
How long is the elimination period in LTC policies?
30 days or more
Health insurance policies issued to small employers are allowed to charge rates that are higher than the average rate charged for all groups with similar case characteristics and similar benefit design characteristics. What is the maximum allowed rate difference?
30%
If health coverage for the dependent children of the insured needs to continue beyond the child's limiting age due to the child's disability, the insurer may require proof of child's incapacity and dependency within how many days of the child attaining the limiting age?
31
In a nonscheduled plan, the insurer will be expected to pay what portion of the fees for basic services?
80%
A surgeon developed a disability and can no longer perform surgeries. However, he is able to teach medicine at the university. He is most likely to collect disability benefits if his disability policy uses which definition of disability?
Own
An insured owns a disability policy and is in an accident which leaves him permanently blind. Which of the following provisions in a disability policy would qualify the insured for benefits, even if the insured is able to resume working?
Own
HMOS can help reduce the cost of health care by providing
PREVENTATIVE CARE
Prior to purchasing a Medigap policy, a person must be enrolled in which of the following?
Part A & B
T/F: pre-existing conditions are permanently excluded from group health policies
TRUE
Describe the taxation of HSA contributions by an individual
Tax-deductible, can use it to pay for out-of-pocket medical expenses
The expense for an autopsy covered under the physical exam and autopsy provision is paid by
The Insurer
In long term care policies, the longer the benefit period, _____________
The higher the premium will be
Who chooses the physician in an HMO?
The individual
In long term care policies, the shorter the benefit period, _______
The lower the premiums will be
The benefit amount under a long term care(LTC) policy is usually expressed as
a fixed dollar amount per day
The Omnibus Budget Reconciliation Act of 1990 (OBRA) requires that large group health plans must provide primary coverage for disabled individuals under what age?
age 65 who are NOT retired
A producer CANNOT act as an agent of an insurer without ?
an insurer appoints an indivual to act on its behalf (agency contract)
Under a Key Person disability income policy, premium payments
are made by the business and are not tax deductible
HIPAA requires that the individual have a previous continuous creditable health coverage for how long?
at least 18 mo
Which is considered a qualified plan: Defined benefits or defined contributions?
both are qualified plans
In a contributory plan, who (employee or employer) contribute to premium payments?
both employees and employer
An insured is receiving hospice care. His insurer will pay for painkillers but not for an operation to reduce the size of a tumor. What term best fits this arrangement?
cost containment
Medicaid is funded by
federal and state governments
An insurance company assures its new policyholders that their premium costs will not increase for a period of at least five years. However, due to increasing financial strain, they plan to raise premium costs for all insureds by 10% over the next two years. What term best describes this act?
fraud
Which factor is considered most important to the underwriting decision for disability coverage than for most of the other forms of insurance?
income
