Insurance license CH 7
SHOP stands for?
Small Business Health Options
Dependent
Someone relying on the insured for support
Time to complete a Proof of loss provision
The insured must finish a completed claim form to the insurer within 90 days of the date of loss
According to the regulations for long-term care partnership policies, how often must insurers provide a statement of benefits to the insured? A Weekly B Monthly C Quarterly D Annually
B
If a health insurance company fails to pay a covered claim within 30 days of the receipt of the claim, they are required to pay interest on that claim at the rate of A 8% per annum. B 10% per annum. C 1% per month. D 12% per month.
B
In Iowa, Long-term Care policies may NOT contain a provision that denies a claim for losses based on a pre-existing condition that lasts for more than A 3 months. B 6 months. C 12 months. D 18 months.
B
How does the Insurance Exchange help applicants?
Compare private health plans Obtain information about health coverage options and eligibility or tax credits Enroll in an appropriate health plan
What are required provisions and coverages for group coverage?
Continuation of coverage- change to individual Prescription contraceptive coverage
A Medicare supplement may A Duplicate benefits provided by Medicare. B Use waivers to exclude coverage for pre-existing diseases. C Contain limitations more restrictive than those imposed by Medicare. D Contain pre-existing condition limitations.
D
When does a group coverage need to change to an individual coverage?
Within 31 days after termination of employment
Notice of claim
Written notice of claim must be given to the insurer within 20 days after the occurrence of any loss covered by the policy
indemnity (n) and who gets it?
a payment for loss of life, beneficiary designation
Claim forms
States the insurer, no later than 15 days after receiving the notice of claim, must furnish the claimant with the forms required for filing proof of loss
Nonrenew
Terminate an insurance policy at its expiration date
When a terminated employee is eligible for continuation of their health insurance coverage under both the laws of the Iowa Insurance Code and the Federal COBRA laws, which of the laws are applied? A Iowa Insurance Code B COBRA C The law selected by the employee D
B
Which of the following statements is true regarding coverage for prescription contraceptives in group health policies issued in this state? A It must be added by endorsement. B It is a mandatory coverage. C Deductibles for this coverage can be higher than for other prescription drugs. D Insurers may restrict benefits for contraceptives.
B
If an insurance company writing individual health benefit plans in Iowa decides to nonrenew all written health benefit plans in Iowa, they will be prohibited from re-entering the market for a period of at least A 180 days. B 1 year. C 3 years. D 5 years.
D
10 essential health benefits
Ambulatory patient services Emergency services Hospitalization Pregnancy, maternity and newborn care Mental health and substance use Prescription drugs Rehab and habilitative services and devices Laboratory services Preventative and wellness services and chronic disease management Pediatric services, including oral and vision care
Expense- incurred contract
Pays health policy benefits as a reimbursement of actual expenses
Eligibility for Affordable Care Act
US citizen or national or be lawfully present in the USA Must live in the USA Cannot be currently incarcerated
An insured purchased a policy to provide coverage on himself, his wife, and their two children. Three years later, the insured's wife gave birth to another child. When will the newborn child be covered by the current policy? A At the moment of birth. B After the insured files the appropriate paper work. C The baby will have to be added on the policy through an additional rider. D Any children born to them after the inception of the contract will not be included on the same contract.
A
Each individual and group health insurance policy must provide coverage for low-dose screening mammograms for determining the presence of breast cancer. How much coverage must be provided for women age 40 to 49? A One biennial mammogram B One semiannual mammogram C One annual mammogram D Only a baseline mammogram
A
For diabetic supplies to be covered under an individual health benefit plan, such supplies or equipment must be A Prescribed by a licensed physician. B Administered by a registered nurse. C Administered in an inpatient setting. D Diabetic supplies are not covered.
A
If a Medicare Supplement policy contains pre-existing conditions limitations, the disclosure must appear as a separate paragraph in the policy and be labeled as A Pre-existing Conditions Limitations. B Exclusions. C Noncovered Claims. D Waiting Period.
A
In Iowa, if an individual wishes to bring a legal action against an insurer to recover on a health insurance policy, how soon can such action commence? A At any time B No sooner than 60 days after written proof-of-loss is furnished to the insurer C No sooner than 3 years after the loss D No sooner than 30 days or later than 5 years after the loss
B
In Iowa, to be marketed as a Long-Term Care policy, the policy, certificate or rider must be designed to provide coverage for at least A 24 consecutive months. B 12 consecutive months. C The period of time until the insured's age 90. D Until the insured becomes eligible for Medicaid.
B
Which of the following statements is true regarding cancellation of a Medicare Supplement policy by an insurer? AIt can only be cancelled on the policy anniversary. BIt can be cancelled at any time as deemed appropriate by the insurer. CIt cannot be cancelled for any reason. DIt can be cancelled for nonpayment of premium.
D
Within how many days must an employee elect continuation of health coverage under COBRA after the termination of the employee's group policy? A 10 B 14 C 30 D 31
D
What has to be covered mandatory?
Diabetes Mammograms Newborn and adopted children Complications of pregnancy
What groups at eligible for group coverage?
Employer groups Labor union/employee organization groups Trustee groups Nonprofit industrial associations
Insurance exchanges (marketplace)
Federally- facilitated marketplace State exchange SHOP Helps applicants
When must claims be paid?
Must be paid within 30 days of receipt
Indemnity contract
Pays health policu benefits to the insured based on a predetermined, fixed rate, regardless of the actual expense incurred
Physical examination and autopsy provision means?
The insurer, at their own expense, has the right to request a physical examination or autopsy of the insured while a claim is pending (where is is not forbidden by law)
What are he grace periods?
7 days for weekly premium policies 10 days for monthly premium policies 31 days for all other policies AFTER THE FIRST
A group life insurance policy issued to an employer to insure employees of that employer, must cover how many employees at the date of issue? A 2 B 10 C 25 D 100
A
If an insurer chooses not to renew all plans, the Commissioner must be given notice how many days prior? A At least 3 days B At least 6 days C At least 9 days D At least 15 days
A
In which of the following cases would a credit disability policy be issued? A If an individual is in debt to a specific creditor, payments will be made for him/her until the return to work. B If a person receives disability benefits, he or she is eligible for credits on their group policies for future disabilities. C A person receiving disability benefits cannot receive a credit disability policy. D If an insured has filed bankruptcy and his premiums are waived, he can be issued a credit disability policy.
A
All of the following are types of care that is provided under LTC's home health care EXCEPT occasional visits by which of the following? A Registered nurses B Licensed practical nurses C Licensed vocational nurses D Pediatric nurses
D
In Iowa, a group insurance policy issued to trustees of a fund established by two or more employers must cover how many eligible, insurable employees at the time of the issue? A 1,000 B 10 C 50 D 100
D
Terms for long term care
Guaranteed renewal Pre existing conditions no longer than 6 months Long term care partnership program
When must payment of claim be done?
Immediately upon receipt of written proof of loss, unless provided by periodic payments
Exempt
Not subject to an obligation
What is time limit on certain defenses?
When 2 years pass, post date of issued policy, no misstatements on the application can be used to void the policy or deny a claim unless the statements were fraudulent aka incontestability provision
The Affordable Care Act requires all U.S. citizens and legal residents to have qualifying health care coverage. This is known as A The individual mandate. B The Insurance Marketplace. C Safe Harbor mandate. D Special enrollment.
A
The Individual Health Insurance Reform Act requires that insurance carriers issuing individual health benefits plans must make available to eligible individuals who apply and agree to pay the premium A Basic health benefit plans. B Specified disease plans only. C Medicare Supplement insurance plans. D Long-term care insurance plans.
A
The Long-term Care Partnership Program creates a partnership between the state government and which of the following? A Medicaid recipients B Medicare recipients C Anyone eligible for long-term care insurance D Social Security recipients
A
To be eligible to be enrolled in the HAWK-I health care program, a child must be A Less than 19 years of age. B A member of a family whose adjusted gross income is below the federal poverty level. C A legal U.S. resident. D A patient in a licensed mental institution.
A
Under what circumstances must an insurer provide benefits for adopted children? A When the policy provides coverage for dependent children of the insured B If an Adopted Child Provision is in the policy C Never; coverage is mandatory only for biological children D If ordered by the Commissioner
A
Long term partnership program policy
A partnership between the state government, private long term care insurance companies, and state residents who wish to purchase this kind of policy
What is an entire contract?
A policy including endorsements and attached papers
Suitability
A requirement to determine if an insurance product is appropriate for a customer
How long is the free-look period for replacement Medicare supplement policies? A 10 days B 20 days C 30 days D 60 days
C
How soon after the receipt of a properly completed claim form and proof of loss must a health insurance company accept and pay or deny a claim? A 10 days B 20 days C 30 days D 90 days
C
In Iowa, the Individual Health Insurance Reform Act was enacted to promote A Low cost health insurance coverage. B Nonmedical underwritten health insurance. C Fair access to health insurance plans. D Group health coverage for all Iowa residents.
C
The Healthy and Well Kids in IA Program (HAWK-I) is funded by A The State of Iowa, only. B The Federal government, only. C Jointly by the State of Iowa and the Federal government. D Donation by Churches and other charitable organizations.
C
To be eligible for tax credits under the ACA, individuals must have income that is what percent of the Federal Poverty Level? A Less than 10% B Between 10% and 100% C Between 100% and 400% D Higher than 300%
C
Under the ACA, health insurance can no longer be underwritten based on which of the following factors? A The applicant's age B The applicant's tobacco use C The applicant's health condition D The applicant's family composition
C
Which of the following events would allow and insurance carrier to nonrenew and individual health benefit plan? A The policyholder submits two or more covered medical claims in a policy year. B A premium is not paid until the grace period has commenced. C The policyholder became eligible for coverage under Medicare. D Any of the above.
C
Which of the following is NOT a requirement for a partnership qualified LTC policy? A The applicant must meet residence requirements for Iowa at the time of issuance. B The policy must provide for inflation protection if the applicant is less than 61 years of age. C The policy must have been issued before January 1, 2010. D The policy must abide by Social Security and federal regulations.
C
When can a legal action take place?
Can be done between 60 days to 3 years after written proof of loss is furnished
Terms for Medicare supplement plans
Cannot duplicate Medicare benefits 30 day free look period Coverage must be guaranteed renewable Pre existing conditions exclusion- no longer than 6 months
In Iowa, group insurance may be written to provide insurance coverage for A Any group of 10 or more individuals that come together for the purpose of purchasing group life insurance. B Any group of individuals. C Any group of 10 or more individuals. D Any group that conforms to one of the descriptions of eligible groups as established by the Insurance Division or that receives special approval from the Commissioner.
D
The Patient Protection and Affordable Care Act mandates that insurers provide coverage for dependent children up to age of A 18 B 19 C 21 D 26
D
To be eligible to purchase a group insurance policy, a nonprofit industrial association must be incorporated for how long? A 1 year B 3 years C 5 years D 10 years
D
Which of the following individuals will be eligible for coverage on the Health Insurance Marketplace? A Someone who has Medicare coverage B A U.S. citizen who is incarcerated C A U.S. citizen living abroad D A permanent resident lawfully present in the U.S.
D
Which of the following is NOT a mandatory coverage in health insurance policies in Iowa? A Prescription contraceptive coverage B Mammograms for women starting at age 35 C Coverage for adopted children D Maternity benefits
D
