Health Exam Questions
*Comprehensive* dental care policies usually...
*pay a percentage* of reasonable and customary charges for *non routine treatment*
Requirements for payment of Social Security disability benefits
- Total and permanent disability for at least 5 months - Fully insured and disability insured - Expected disability of 12 months or longer or ending in death
A Medicare SELECT policy differs from a regular Medigap policy in that it...
-Provides *less* coverage -Cheaper
Employer-paid premiums for employee group health insurance are generally...
-Tax-deductible to the employer -Nontaxable to the employees
The type of health insurance policy most likely used to cover all students attending a large university
A blanket policy
Example of what qualifies as a compensable injury under workers compensation coverage
A factory worker fractures an elbow while working overtime
The usual payment arrangement under a *Preferred Provider Organization* contract is...
A fee for each service
A company that is licensed to sell insurance in a particular state
An Authorized Company
An applicant for insurance may pay the initial premium and receive a document from the agent indicating that if the policy is issued as requested, coverage begins on the date of the document. What is this document called?
Conditional receipt
What term applies to the dollar amount the insured must pay between the basic policy and the major medical coverage?
Corridor deductible
What is the underlying purpose of a *second injury fund?*
To promote the employment of previously injured or physically handicapped workers
*Individuals* covered by a *group plan* receive...
certificates of insurance
COBRA protects *dependents* of employees by...
mandating for them the *same extension and conversion privileges available to employees covered by group plans*
*Required Provision 10* indicates that if the insurer wants to have an autopsy performed while a claim is pending, the insurer...
may do so if it is not forbidden by law and if the insurer pays for it
In Health Maintenance Organizations, the use of a primary care physician or PCP is common as part of...
the *Gatekeeper System*
*Required Provision 4* addresses reinstatement of a lapsed policy. According to this provision, when an insured applies for reinstatement and receives a conditional receipt, how long does the insurer have to approve or deny reinstatement before the policy will be automatically reinstated?
45 days from the date of the conditional receipt
What is an example of a *producer cooperative* ?
Blue Cross/Blue shield organizations
Who pays the taxes that finance Social Security benefits?
Employers and employees, *in equal contributions*
The *Medical Information Bureau* is a nonprofit organization supported by whom?
Insurance companies
What does Medicaid do?
Provides medical benefits for certain *low-income people, for the disabled, and for families with dependent children*
What type of disability policy covers a *fixed period of time* and provides funds for *long-term commitments* if an *owner or key employee* of a business is disabled?
Reducing term disability coverage
Under what circumstances do major medical policies usually provide for restoration of benefits?
Restoration usually occurs after a specified dollar amount of benefits has been exhausted and after the insured has proved insurability
Primary support for Medicare Part A comes from...
Social Security payroll taxes
When many major medical polices reach a certain dollar amount, the insured no longer shares in the cost of expenses; the insurer pays 100% of remaining covered charges. This is referred to as the ...
Stop-loss limit
Under a *credit health policy*, what is the maximum amount of any accidental death benefit included?
The amount of the *outstanding indebtedness* at any given time
With regard to *group insurance*, who has the responsibility to apply for coverage, provide information about the group, maintain the policy, and pay premiums?
The master policyowner
Trent is named by the insured, Nancy, as the first in line to receive the death benefit provided by Nancy's accident policy. Their daughter Elaine is named as second in line to receive the benefit. What does this make Trent and Elaine?
Trent = *Primary* beneficiary Elaine = *contingent* beneficiary
Under what circumstance are *disability income benefits* received as *nontaxable* income to the recipient?
When the *employee* has paid the premium
A certain health insurance policy states that the insurer will *not refuse to renew the policy* and furthermore, the insurer *may not cancel the policy*. However, the insurer may change the premium by classes of insureds. This policy is...
a guaranteed renewable policy
Normally, Blue Cross/Blue Shield makes payments for medical expenses...
directly to the providers
*Medicare supplement insurance* is designed to...
pay at least some of the health care costs that Medicare will not pay
A disability that is *presumed to result from the same or a related cause of prior disability* is called a...
recurrent disability
Usually, conversion may be made from a family policy to an individual policy *without* evidence of insurability if...
the individual does so *within 31 days after the family coverage ends*
Concealment is...
the withholding of information that should have been provided to an insurer
An insured's disability income policy defines *total disability* as "the insured's inability to perform the duties of *any occupation* for which he or she is reasonably qualified by education, training, or experience." This definition is known as the...
*"Any Occupation"* and is *more* restrictive than other definitions
According to *Required Provision 11*, the insured is *prevented from filing suit against the insurer* for at least...
*60 days* and *not longer than 3 years* from the date of proof of loss
As compared to individual disability income policies, group disability income policies are generally...
*Less* costly and have *more* liberal provisions
*Optional provisions 1 and 2*, addressing changes in occupation and misstatement of age, permit the insurer to do what?
*Pay indemnities equal to benefits that would have been purchased at the premium paid* had the insurer known the facts when the premium was established
According to *Optional Provision 8*, if the insurance company cancels a policy, on what basis must prepaid premiums be returned to the insured?
*Pro rata basis* = ALL unearned premium is returned to the insured
Benefits provided under *Part A* of Medicare
- Inpatient hospital care - skilled nursing facility care - hospice care (Physicians' services for inpatient care NOT PROVIDED)
*Group credit health insurance* requires what?
- Master policyowner - Minimum number of debtors - Premium payment by each debtor Does *NOT* require a medical exam
Reasons an application is important
- The application becomes part of the policy when attached to the policy - The application helps to more fully identify the applicant - Statements made in the application become the basis for issuing the policy
These are *true* concerning a *coordination of benefits* situation
- The group insurer for the person with the claim is primary -The group insurer for the spouse of the person with the claim is secondary -Where children are involved, the primary group insurer is the insurer for the parent whose birthday comes first in the year
Heath Maintenance Organizations are required to provide for all of the following
- emergency services - preventive services - physicians' services *DOES NOT* provide for *prescription drugs*
Noncancellable Policies
1. Also called a noncancellable and guaranteed renewable policy 2. The only right to cancel the noncancellable policy is for nonpayment of premiums 3. The insurer may regain the right to cancel or not to renew when the insured reaches an age specified in the policy
Each of the following would be found in the insuring clause of an insurance policy
1. General scope of the coverage 2. Conditions under which benefits are payable 3. Definitions (Name of the insured is *NOT* included)
These are true concerning the notice of claim and claim forms according to Required Provisions 5 and 6
1. If the insurer *fails to send the insured claims forms within 15 days* after the insured gives notice of the claim, the insured *may submit written proof of loss* 2. Notice to the insurer may be given by a beneficiary of the insured on the insured's behalf 3. Notice provided to any authorized agent of the insurance company is considered to be proper notification to the insurer
Who is eligible for Medicare coverage?
1. People age 65 and older who are eligible for Medicare coverage 2. People age 65 and older NOT eligible for social security, BUT are willing to pay a monthly premium 3. People of ANY age who have been entitled to disability benefits for 24 months
All of the following are alternatives an insurer has when asked to insure a substandard risk
1. Reject the risk 2. Attach a rider to the policy excluding certain coverages or conditions 3. Charge a higher than standard premium (Issue the policy with a probationary period after which the insurer may continue or cancel the policy is NOT AN ALTERNATIVE)
In noncontributory group plans, how many eligible employees must be covered by the plan?
100%
In order to be qualified, a long-term care policy must require assistance with *how many activities of daily living (ADL's)* before benefits may be paid?
2
According to *Required Provision 2*, unless an insured has made fraudulent misstatements, a policy is *incontestable* after...
2 years
What is the minimum grace period, provided in Required Provision 3, for all policies *other* than monthly or weekly premium policies?
31 days
A HMO in a certain city contracts with an independent medical group to provide services to HMO subscribers. The HMO pays the *group organization*, rather than paying the individual medical practitioners. What type of *HMO structure* is this?
A *Group Network*
What is a *Multiple Employer Trust* (MET) ?
A legal entity that *small employers* may join to become eligible for group insurance
Application (description)
A written request from an applicant to an insurer requesting the insurer to issue a policy on the basis of the information in the application
What does the *"Free Look"* provision do?
Allows the insured to look over the issued policy for a specific number of days and return it for a premium refund if desired
*Optional Provisions 3, 4, 5 and 6* deal with situations where an insured can receive *more* money from loss of time benefits than from working, or *more* for reimbursement of medical expenses than these services cost. This is...
Called *Overinsurance* and can be remedied by each insurer's paying proportionate benefits or a single insurer allowing the insured to choose the policy from which benefits will be paid
The Health Maintenance Organization concept that service providers are paid a *fixed monthly fee for each member* is called...
Capitation
Second surgical opinions, precertification, concurrent and retrospective reviews, and outpatient/ambulatory services are all elements of a cost-containment system commonly known as...
Case management
What term describes the concept that the insurer and the insured *share the cost of medical expenses*, with the insurer bearing the greater share?
Coinsurance
What term describes a situation where a policy owner *transfers a portion of his or her rights in an insurance policy to another party in order to secure a debt* to that party?
Collateral assignment
The optional short-term disability income benefit that pays a lump sum for specified injuries
Elective indemnity benefit
In order to obtain group insurance *without* providing evidence of insurability, what do eligible individuals generally have to do?
Enroll within a specified eligibility period
The factor in premium computation that has to do with the *recordkeeping and statistical analysis* insurance companies perform is..
Experience
All medicare supplement (or medigap) policies must...
Have the same core benefits
Type of health care provider that provides both the health care services and the health care coverage
Health Maintenance Organization (HMO)
What waives the elimination period in a disability rider?
Hospital confinement rider
*This represents certain consumer safeguards enacted by states* and patterned after a model act developed by NAIC
Information and Privacy protection Act
A certain major medical policy states a *maximum* number of days for which convalescent care will be paid as well as a *maximum* number of X-rays that will be paid for under any one claim. These are examples of...
Inside limits
Dread disease, travel accident, vision care, and hospital indemnity policies are all examples of what?
Limited Policies
When may agents change a policy or waive its provisions according to Required Provision 1
NEVER
*Required Provision 7* indicates that except in the absence of the insured's legal capacity, if it was not reasonably possible for the insured to provide proof of loss as required in a policy, the *latest time the proof of loss may be furnished* is...
One year from the time proof is otherwise required
Which part of medicare requires premium payment by most eligible participants?
Part B, supplementary medical insurance
Before Cranston was disabled, he was a full-time engineer earning about $70,000 annually. Now, two years later, he is able to work part-time, earning about $25,000 annually. It is likely that Cranston would be classified as...
Partially disabled
Major medical policies may include a *type of deductible* wherein the insured *pays a new deductible amount for each different event* that causes medical expenses to be incurred. This is the...
Per-cause deductible
Under workers compensation, a disability that is a *permanent physical impairment* leaving the individual *incapable* of performing the *previous* regular occupation, but *capable* of performing some other type of work
Permanent partial disability
In a *disability income policy*, there is a period during which no benefits will be paid for illness of any kind. This period usually does not apply to accidents, only illness. The term that describes this interim is the...
Probationary period
When medical expense policies *do not state specific dollar benefit amounts*, but instead base payments upon the charges for like services in the same geographical area, benefits are designated as which of the following?
Usual, customary and reasonable charges
A health insurance policy includes an endorsement indicating the insurer will allow the policy to continue in force *without further premiums* if the insured is totally and permanently disabled. What endorsement is attached to this policy?
Waiver of Premium
Brenda names her husband as the beneficiary of the accidental death benefit in her health policy. She has relinquished her right to change the beneficiary designation. According to the required provision 12, Brenda's husband is what?
an irrevocable beneficiary
A health insurance policy that the insurer may choose *not* to renew *only on the premium due date* is called...
an optionally renewable policy
A *third-party administrator* is...
an outside organization that manages employers' self-insured plans
Under *Optional Provision 7*, when premiums are unpaid at the time a claim is submitted, the insurer may...
deduct unpaid premiums from benefits before paying the claim
Jay, who is employed by X Company, is assigned to work temp. in another state. Jay gets injured on the job while in the other state. The state he is employed must pay workers comp. This indicates that the Workers comp. law in the state where Jay was hired...
includes extraterritorial provisions
An insured's accident policy uses the phrase *"accidental bodily injury"* to define what constitutes accidental injury. This phrase...
is *less restrictive* than the phrase "accidental means"
*Optional Provision 9*, which deals with conformity to state statutes, provides...
that policy provisions in *conflict with state statutes* where the insured resides are *automatically amended to conform to the minimum requirements of the law*
(Correct statement: Long Term Care policies) *Present policies are more likely to pay benefits regardless of*...
the level of care required by the insured
