Chapter 11

In Ohio, a small group employer is comprised of

2-50 employees

Under long-term care insurance, which of the following MUST an insurer offer to each policyowner at the time of purchase?

An inflation protection feature

Claim forms

An insurance company will send forms for filing proof of loss to a claimant within 15 days after company receives notice of a claim.

If a licensee is suspended for non-renewal, the licensee may apply for reinstatement within

the 12 month period following the date when the license should have been renewed

Replacement

Before a policyowner replaces an existing individual health insurance policy, all of the following types of provisions in the new policy need to be reviewed:• Coverage exclusion • Benefit levels • Coverage limitations

With a scheduled dental policy, how are covered expenses paid?

Benefits are limited to a specific maximum dollar amount per procedure

Under the Affordable Care Act, a large employer that does NOT provide health insurance and owes an employer mandate penalty MUST pay an annual penalty, which is calculated by multiplying $2,000 by

"the number of full time employees minus 30". According to the Affordable Care Act, if a large employer does NOT provide health insurance and owes an employer mandate penalty, the annual penalty is calculated by multiplying $2,000 by the number of full time employees minus 30.

Under Ohio continuation rules, an employer with fewer than 20 employees must allow terminated employees to continue accident and health coverage for at least

12 months

In order to transact insurance business in Ohio, an insurance agent must

18 years old

An employer may qualify for health care tax credits through SHOP Marketplace if that employer has fewer than how many employees?

25

The superintendent must examine the financial affairs of each admitted insurer operating in Ohio at least once every how many years?

3

A licensee who is required to take continuing education must include how many ethics coursework hours?

3 hours

After the date of marriage, an insurer is REQUIRED to provide what MINIMUM period of time for an employee to add a new spouse to a small group health plan?

30 days

In Accident and Health plans, premiums paid less frequent than monthly require a minimum Grace period of at least

7 days

An insured MUST submit a proof of loss on a health insurance claim within how many days after the date of loss?

90

Endodontics

Endodontics is the branch of dentistry dealing with diseases of the dental pulp. Root canals would be an example. Endodontics is commonly excluded or limited from a dental policy.

Incontestable period

Except for fraud, the time after issuance of a policy during which an insurance company may contest an accident and health insurance claim due to the statements on an application is 2 years.

Reinstatement

If a health policy is reinstated after it had lapsed for nonpayment, there is a waiting period of 10 days before a claim covering sickness will be covered. Injuries sustained from an accident, however, will be covered immediately.

Falsifying the terms, benefits, advantages, or conditions of an insurance policy is an example of which of the following?

Misrepresentation

Which one of the following is a domestic insurer?

One formed under the laws of Ohio

Orthodontics

Orthodontics is the treatment of irregularities in the teeth (esp. of alignment and occlusion) and jaws, including the use of braces.

Periodontics

Periodontics is a dental specialty that involves the prevention, diagnosis, and treatment of disease of the supporting and surrounding tissues of the teeth or their substitutes. It also involves the maintenance of the health, function, and esthetics of these structures or tissues.

The branch of dentistry which deals with the replacement of missing parts is called

Prosthodontics

Prosthodontics

Prosthodontics is a branch of dentistry dealing with the replacement of missing parts using biocompatible substitutes, such as bridgework or dentures.

What is the term used when exchanging a new policy for one already in force?

Replacement

Grace Period

The grace period for health and accident insurance is required to be no less than 7 days for weekly premium policies, 10 days for monthly premium policies and, 31 days for all other policies. If premium is paid within the grace period, coverage shall remain in effect.

Which of the following statements regarding an examination of an insurer's books and records by the superintendent is true?

The insurer must not impede an examination and is required to assist in the examination procedures

What is a certificate of authority?

The license required for an insurer to conduct business in the state

What is the renewal date of a resident insurance agent's license?

The license term is every 2 years, based on the last day of the agent's birth month.

Metal levels

There are four tiers of "qualifying health plans" you or your employer can purchase on the exchange. • Bronze Plans: 60% actuarial level of coverage provided • Silver Plans: 70% actuarial level of coverage provided • Gold Plans: 80% actuarial level of coverage provided • Platinum Plans: 90% actuarial level of coverage provided

Through what means can an unauthorized insurer place business in Ohio?

Through limited lines agent

Under US Code 1033, crimes by or affecting persons engaged in the business of insurance which affect interstate commerce are prosecuted by the

US Attorney General

Notice of claim

Written notice of a claim must be given within 20 days after a covered loss starts or as soon as reasonably possible.

Proof of loss

Written proof for any loss must be given to the insurance company within 90 days.

A licensed agent who lives in another state and transacts insurance in Ohio is called

a nonresident agent

Group dental plans will frequently place a limit on annual benefits in order to minimize

adverse selection

An agent may begin to solicit insurance ONLY when

appointed by an insurer

Under small group health benefit plans, a carrier may discontinue coverage or may refuse to renew such a plan if the employer

fails to pay the premium prior to the end of the grace period

An insurer MUST offer a Long-Term Care Policy or certificate that

has a nonforfeiture value

When the superintendent believes an agent is causing substantial and material harm, the superintendent has the authority to

issue a cease and desist order against the agent

All Health Benefit Plans issued after January 1, 2014 must provide

preventative health services

A cease and desist order issued by the superintendent against an agent

prohibits a specific practice listed in the order

No existing agent's license will be revoked until

the agent has been afforded a right to a hearing on the charges

An insurer may non-renew an individual health benefit plan for all the following reasons EXCEPT

the individual is eligible for health care benefits from the Veterans Administration

Who may terminate an agent's appointment?

the insurer

A policyholder's unmarried child is incapable of self support and has proof of incapacity. The child is provided medical care coverage under the parent's policy

until policy termination

An agent may share commission in which one of the following scenarios?

with another licensed but unappointed agent

Violations of US Code Title 18 section 1033, may result in

Fine and/or imprisonment

When an accident and health policy requires payment of an additional premium to provide coverage for a newborn, how many days after the birth is the first payment due?

31

If a health insurance claim is not promptly paid, legal action may be taken against the insurer after

60 days from the date proof of loss is furnished

Which of the following is a characteristic of a non-admitted insurer?

A non-admitted insurer is not afforded protection by the guaranty fund

Entire contract

A provision that the policy, application, and all attachments shall constitute the entire contract between the parties.

Right to Examine (Free Look)

After purchasing an individual health insurance contract, policyowners have 10 days from the date of receiving the policy to return it for a full refund for any reason.

In Ohio, when an advertisement for accident and health insurance refers to dollar amount benefits, the advertisement must also disclose

Any applicable benefit reduction

How are health plans classified according to the Affordable Care Act?

Bronze, Silver, Gold, Platinum

Which of the following acts by an insurer, if committed without just cause and performed with such frequency as to indicate standard operating procedures, constitutes an unfair claims settlement practice?

Failing to adopt and implement reasonable standards for the prompt investigations of claims

A deliberate lie by an insured to the insurer to obtain a lower premium is an example of

fraud

Each application for long-term care insurance shall contain clear and unambiguous questions to determine the health condition of the applicant EXCEPT applications for

guaranteed issue

The PRIMARY purpose of the Fair Credit Reporting Act is to

protect consumers with guidelines regarding credit reporting and distribution

How long can an insurer exclude coverage for a preexisting condition on a Medicare Supplement Policy?

6 months

Ohio requires advertisements for accident and health insurance policies covering ONLY a specified illness to prominently display

A statement that the policy is limited

Payment of claims

If benefits are not paid on a timely basis, the benefits paid shall bear simple interest from a date 2 months after satisfactory proof of loss was received by the insurer.

Publishing information that is false and maliciously critical to an insurer and intended to cause injury is a prohibited practice known as

defamation

Which of the following must be included in an outline of coverage for a Medicare supplement insurance policy?

description of policy benefits

The superintendent is NOT responsible for

endorsing insurers

Legal Actions

No legal action can be initiated within 60 days after proof of loss has been submitted to the insurance company. In addition, no legal action can be initiated after 3 years from the initial time written proof of loss has been provided.

Dental Plans

Occasionally, dental insurance is part of a health benefits package with a single deductible called an integrated deductible, applying to both medical and dental coverage. More often, however, dental coverage and claims are handled separately with a separate deductible. There also may be a probationary period in group dental insurance to help hold down coverage for preexisting conditions.

The Ohio insurance superintendent is appointed to office and has all of the following powers and duties EXCEPT

enact legislation dealing with insurance

A policyholder's unmarried child is incapable of self support due to physical disability. The child is provided medical care coverage under the parent's policy

until policy termination with proof of incapacity

Which of the following does restorative dental treatment cover?

Crowns

A hospital or medical expense policy will typically cover dental treatment expenses under which circumstance?

Dental treatment is needed to repair an injury

Which of the following is permitted in an advertisement for an insurance policy?

The insurer's name

When the insured gives birth, coverage for eligible newly born children consists of coverage for injury or sickness including

birth abnormalities

When an insurance appointment with an agent is terminated, the party that must notify the agent of the termination is the

insurer