Health Insurance Exam

Which of the following would best describe total disability?

A person's ability to work is significantly reduced or eliminated for the rest of his/her life.

When the policy premium wasn't submitted with the application, what should the agent obtain from the insured upon policy delivery?

A statement of good health

Which of the following is NOT covered under a long-term care policy?

Acute care in a hospital

Which of the following statements concerning group health insurance is CORRECT?

The employer is the policyholder.

Hospice care is intended for

The terminally ill.

An insured has Medigap insurance and later becomes eligible for Medicaid. If the person elects to receive Medicaid coverage, for how many years can Medigap benefits and premiums be suspended?

2

An agent who has had formal disciplinary action taken against them by a state regulatory agency must notify the Commissioner of this within

30 days

Which of the following would be considered a routine procedure?

Annual check-up

According to the provisions of the Patient Protection and Affordable Care Act, all of the following are required preventive care services EXCEPT

Cervical cancer exams for all women starting at age 40.

All of the following statements are true of a Combination Dental Plan EXCEPT

It is also known as the Superimposed Plan.

The Commissioner obtains a restraining order against a person who has violated an insurance law. The person continues the violation for 10 days. The person will have to pay a fine of

$0

Which of the following would be a typical maximum benefit offered by major medical plans?

$1 Million

An insurer charges a $100 copay for an insured's intravenous chemotherapy treatment. What is the maximum copay the insurer can charge for oral chemotherapy treatment under the same policy?

$100

Any person who violates an insurance statute or rule of Wisconsin can be fined up to

$5,000.

An insured was involved in an accident and could not perform her current job for 3 years. If the insured could reasonably perform another job utilizing similar skills after 1 month, for how long would she be receiving benefits under an "own occupation" disability plan?

2 years

All group policies that cover inpatient hospital services must provide how much coverage for such services for the treatment of alcoholism, drug abuse, and nervous or mental disorders?

$7,000

What is the shortest possible elimination period for group short-term disability benefits provided by an employer?

0 Days

All of the following are advantages of an HMO or PPO for a Medicare recipient EXCEPT

1. Elective cosmetic procedures are covered.

Which of the following is true regarding METs?

1. They allow several small employers purchase less expensive insurance together.

A policyholder may return (for a full premium refund) any individual disability policy within how many days of receiving it?

10

With few exceptions, every disability insurance policy must provide coverage for blood lead tests for children under what age?

10 years old

According to OBRA, what is the minimum number of employees required to constitute a large group?

100

In order to collect Social Security disability benefits, the claimant must be able to demonstrate that the disability will last at least

12 MOnths

COBRA applies to employers with at least

20 employees

An agent is presumed to have exceeded the occasional exchange of business if the agent places more than how many insurance risks per calendar year with all insurers?

25

Any person who violates an insurance statute or rule of Wisconsin can be imprisoned for up to how many years?

3

People who have been insured for how many months under a group contract must be allowed to continue group coverage or convert to an individual contract if the group coverage ends?

3 months

How long are oral contracts valid in Wisconsin?

30 Days

What is the duration of the free-look period for Medicare supplement policies?

30 Days

Within how many days of receiving a request to use experimental treatment on an insured, the insurer must issue a decision on whether it will cover the experimental treatment?

5

Jason is insured under his employer's group health insurance. He splits the cost of the premiums with his employer. This is an example of

A contributory plan.

According to the Law of Agency, a principal is represented by a/an

Agent

Which of the following would NOT be a violation of state insurance regulations?

Agent C uses her license to write only business other than controlled.

What documentation grants express authority to an agent?

Agent's contract with the principal

When transacting business in this state an insurer formed under the laws of another country is known as a/an

Alien Insurer

In which Medicare supplemental policies are the core benefits found?

All Plans

In reference to the standard Medicare Supplement benefits plans, what does the term standard mean?

All providers will have the same coverage options and conditions for each plan.

Which of the following must the patient pay under Medicare Part B?

All reasonable charges above the deductible according to Medicare standards

When an insured purchased her disability income policy, she misstated her age to the agent. She told the agent that she was 30 years old, when in fact, she was 37. If the policy contains the optional misstatement of age provision

Amounts payable under the policy will reflect the insured's correct age

If an insurer meets the state's financial requirements and is approved to transact business in the state, it is considered to be

Authorized

A banker is ready to close on a customer's loan. The bank is prepared to offer the loan but only if the customer purchases a life insurance policy from the bank in the amount of the loan. This is an example of

Coercion

Combination plans are comprised of two types of plan features: basic and

Comprehensive

A health insurance plan that covers all accidents and sicknesses that are not specifically excluded from the policy is referred to as a

Comprehensive plan.

An insured is admitted to the hospital for surgery on a herniated disk. The insurance company monitors the treatment and progress in order to make sure that everything proceeds according to the insurer's schedule. This is called

Concurrent review.

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

Which of the following is NOT true of basic medical expense plans?

Coverage for catastrophic medical expenses

Which of the following is NOT a cost-saving service in a medical plan?

Denial of coverage

If the head of the Department of Insurance has ruled a group can apply for group health insurance, it is considered a

Discretionary group.

Tim and Tom are twins. When they applied for life insurance from Company A, the insurance company found that while neither of them smoked and both have a very similar lifestyle, Tim was in a much stronger financial position than Tom. Because of this, the company charged Tim a higher rate for his insurance. This practice would be

Discrimination

Which of the following is NOT covered by Health Maintenance Organizations (HMOs)?

Elective services

The requirement that agents not commingle insurance monies with their own funds is known as

Fiduciary Responsibility

How many pints of blood will be paid for by Medicare Supplement core benefits?

First 3

Welfare benefits include all of the following EXCEPT

Holiday pay.

All of the following would fall under the definition of Durable Medical Equipment EXCEPT

Hospital blankets.

A Health insurance policy lapses but is reinstated within an acceptable timeframe. How soon from the reinstatement date will coverage for accidents become effective?

Immediately

In which of the following locations would skilled care most likely be provided?

In an institutional setting

Coverage of a dependent child who has now reached the maximum child age limit cannot be ended while the child continues to be

Incapable of self-sustaining employment because of mental retardation or physical handicap. & Chiefly dependent upon the person insured under the policy for support and maintenance.

In long-term care (LTC) policies, as the benefit period lengthens, the premium

Increases

When a person applies for Medicare supplement insurance, whose responsibility is it to confirm that the applicant does not already have accident or sickness insurance in force?

Insurer

All of the following are true regarding small group coverage in Wisconsin EXCEPT

Insurers are prohibited from ever increasing rates.

If an employer provides health insurance for its employees, which of the following is true regarding pregnancy coverage?

It must be covered to the same extent as any other medical condition.

Which of the following statements is NOT correct concerning the COBRA Act of 1985?

It requires all employers, regardless of the number or age of employees, to provide extended group health coverage.

For the reported losses of an insured group to become more likely to equal the statistical probability of loss for that particular class, the insured group must become

Larger

If a business owner becomes totally disabled, a Business Overhead Expense policy will pay all of the following EXCEPT

Loss of the owner's income.

All of the following statements describe a MEWA EXCEPT

MEWAs are groups of at least 3 employers.

Julie must have orthodontic work performed on her incisors. Which type of service would this be called, under a nonscheduled plan?

Major service

If a dental plan is integrated, it is combined with what type of plan?

Medical

To sign up for a Medicare prescription drug plan, individuals must first be enrolled in

Medicare Part A

An insured is involved in a car accident. In addition to general, less serious injuries, he permanently loses the use of his leg and is rendered completely blind. The blindness improves a month later. To what extent will he receive Presumptive Disability benefits?

No benefits

Insurers may not terminate or limit a contract entered into or renewed with an agent based on all of the following EXCEPT

None of the above. All are unfair grounds of termination.

Under which plan does preventative dental treatment not apply toward the deductible?

Nonscheduled

Premium payments for personally-owned disability income policies are

Not tax deductible.

If one takes Social Security retirement benefits at age 62, what needs to be done at age 65 to qualify for Medicare?

Nothing

An insured's health claim internal appeal was denied. The insurer must do all of the following EXCEPT

Offer a payment plan

Prior to purchasing a Medigap policy, a person must be enrolled in which of the following?

Parts A & B of medicare

Which of the following is the most common time for errors and omissions to occur on the part of an insurer?

Policy Delivery

A man's physician submits claim information to his insurer before she actually performs a medical procedure on him. She is doing this to see if the procedure is covered under the patient's insurance plan and for how much. This is an example of

Prospective review.

Under the Fair Credit Reporting Act, if the consumer challenges the accuracy of the information contained in his or her report, the reporting agency must

Respond to the consumer's complaint.

Which of the following are responsible for making premium payments in an HMO plan?

Subscribers

When a group disability insurance policy is paid entirely by the employer, benefits paid to disabled employees are

Taxable income to the employee.

Your client has a Social Insurance Supplement (SIS) rider on his disability policy. After he becomes disabled, he receives payments from the company. Shortly thereafter, he also begins receiving Social Security benefit payments. Which of the following will happen?

The SIS payment will be reduced dollar-for-dollar by the Social Security benefit payment.

Which of the following is true about the requirements regarding HIV exams?

The applicant must give prior informed written consent

An insured has a daughter who is covered as a dependent under the insured's health insurance policy. On her 17th birthday, the daughter had a baby. Which of the following is true regarding the baby's health coverage?

The baby will be covered for a year.

An insured who has an Accidental Death and Dismemberment policy loses her left arm in an accident. What type of benefit will she most likely receive from this policy?

The capital amount in a lump sum

Which of the following is a characteristic of a Reciprocal Insurance Exchange?

The chief administrator of the insurer is called an "attorney-in-fact".

Which of the following definitions would make it easier to qualify for total disability benefits?

The more liberal "own occupation"

An individual applies for a life policy. Two years ago he suffered a head injury from an accident, so he cannot remember parts of his past, but is otherwise competent. He has also been hospitalized for drug abuse, but does not remember this when applying for insurance. The insurer issues the policy and learns of his history one year later. What will probably happen?

The policy will not be affected.

An insured is upset that her new health insurance policy was delivered to her by certified mail and not through her agent. Which of the following is true?

There is nothing wrong with this form of policy delivery.

How are employer contributions to Health Reimbursement Accounts treated in regards to taxation?

They are tax deductible.

When employees are actively at work on the date coverage can be transferred to another insurance carrier, what happens to coinsurance and deductibles?

They carry over from the old plan to the new plan.

A medical expense policy that establishes the amount of benefit paid based upon the prevailing charges which fall within the standard range of fees normally charged for a specific procedure by a doctor of similar training and experience in that geographic area is known as

Usual, customary and reasonable.

When can a Long-Term Care policy deny a claim for losses incurred because of a pre-existing condition?

Within 6 months of the effective date of coverage

Which of the following losses will be covered by a group medical expense policy?

a pre-existing condition

On a major medical insurance policy, the amount that an insured must pay on a claim before the insurer will pay is known as

deductible

If the Commissioner issues an order without having conducted a hearing, the person aggrieved by the order may demand a hearing within how many days after the order was mailed?

30

Forcing a client to buy insurance from a particular lender as a condition of granting a loan is defined as

Coercion

Which of the following terms describes a situation in which an agent and policyholder act together to defraud the insurer?

Collusion

Concerning Medicare Part B, which statement is INCORRECT?

It is fully funded by Social Security taxes (FICA).

Which of the following must be present in all Medicare supplement plans?

Plan A

An individual purchased a Medicare supplement policy in March and decided to replace it 2 months later. His history of coronary artery disease is considered a pre-existing condition. Which of the following is true?

The pre-existing condition waiting period fulfilled in the old policy will be transferred to the new policy, the new one picking up where the old one left off.

Which of the following is an example of a producer's fiduciary duty?

The trust that a client places in the producer in regard to handling premiums.

What is the purpose of the ADEA?

To prohibit age discrimination in employment

What is the purpose of COBRA?

To provide continuation of coverage for terminated employees

Income replacement contracts agree

To replace the insured's income up to a stated percentage if the insured suffers a loss due to a covered accident or sickness.

Under the Physical Exam and Autopsy provision, how many times can an insurer have the insured examined, at its own expense, while a claim is pending?

Unlimited

A resident agent must pay a biennial regulation fee of

$35

Every small employer carrier must actively offer to small employers at least how many health benefit plans?

2 Plans

HIPAA applies to groups of

2 or more

How long must an insurer retain an advertisement for its long-term care policies?

3 years

To attain currently insured status under Social Security, a worker must have earned at least how many credits during the last 13 quarters?

6 credits

Which statement best defines a Multiple Employer Welfare Arrangement (MEWA)?

A joining together by employers to provide health benefits for employee

Where would Long-term care services be rendered?

A nursing home or one's own home

Which of the following groups would probably be covered by blanket insurance?

A university's sports team

Insurance policies are not drawn up through negotiations, and an insured has little to say about its provisions. What contract characteristic does this describe?

Adhesion

Which of the following long-term care benefits would provide coverage for care for functionally impaired adults on a less than 24-hour basis?

Adult day care

The Omnibus Budget Reconciliation Act of 1990 (OBRA) requires that large group health plans must provide primary coverage for disabled individuals under

Age 65 who are not retired.

Under which condition would an employee's group medical benefits be exempt from income taxes?

An employee's group medical benefits are generally exempt from taxation as income.

Which of the following hospice expenses would NOT be covered in a cost-containment setting?

Antibiotics

Disability income coverage specifies that the policy covers the insured if he is unable to perform any job for which he is qualified. In this case, total disability is defined as

Any occupation - more restrictive than other definitions.

Which of the following is NOT required to be stated in the outline of coverage provided with a long-term care policy?

Basic information about supplementary policies

A dental plan that provides coverage based upon a specified maximum scheduled amount for each procedure and pays on a 'first dollar' basis with no deductible or coinsurance is a

Basic or scheduled plan

A man is still employed at age 65 and is now eligible for Medicare. He wants to know what health insurance coverage he is eligible to receive. Which of the following options are available to him?

Both group health and Medicare

Which of the following options best depicts how the eligibility of members for group health insurance is determined?

By conditions of employment

All of the following are true about group disability Income insurance EXCEPT

Coverage applies both on and off the job.

Which of the following is true regarding coverage for treatment of alcoholism in group disability policies issued in this state?

Coverage is mandatory up to stated limits.

The insurance policy, together with the policy application and any added riders form what is known as

Entire contract.

According to the PPACA metal levels classification, if a health plan is expected to cover 90% of the cost for an average population, and the participants would cover the remaining 10%, what type of plan is that?

Gold

What is the benefit of experience rating?

It allows employers with low claims experience to get lower premiums.

Which of the following statements is NOT true concerning Medicaid?

It consists of 3 parts: Part A: hospitalization, Part B: doctor's services, Part C: disability income.

Which is true regarding HMO coverage?

It is divided into geographic territories

Which of the following information regarding an insured is NOT included in an Investigative Consumer Report, which is requested by an underwriter?

Medical history

Under the Affordable Care Act, which classification applies to health plans based on the amount of covered costs?

Metal level classification

If an insurer plans to stop providing a specific type of group health insurance plan in this state, the insurer must notify the

NAIC

Which of the following is NOT correct regarding false statements by a person engaged in the business of insurance?

Only written statements are considered unlawful

All of the following are covered by Part A of Medicare EXCEPT

Physician's and surgeon's services.

What provision may allow a small employer health benefit plan to exclude coverage for a pregnancy existing on the effective date of the coverage?

Pre-existing condition

Which of the following is correct regarding the taxation of group medical expense premiums and benefits?

Premiums are tax deductible and benefits are not taxed.

At what point during the policy application process must replacement forms be completed?

Prior to submitting an application

Which of the following may NOT be included in an insurance company's advertisement?

That its policies are covered by a state Insurance Security Fund

Health plan issuers are prevented from collecting genetic information for underwriting purposes or limited in their requests for genetic tests by

The Genetic Information and Nondiscrimination Act.

An agent makes a sales pitch that contains blatant lies about the insurer and its competitions. Who will ultimately be held legally responsible for this?

The Insurer

Peril is most easily defined as

The cause of loss insured against

For an individual who is eligible for Medicare at age 65, and who is still employed and covered under the employer's plan, which of the following is true?

The employer plan is primary coverage, and Medicare is secondary coverage.

What is a characteristic of a conventional fully-insured plan?

The insurer assumes the risk of paying the cost of medical expenses occurring during the policy period

An applicant is considered to be high-risk, but not so much that the insurer wants to deny coverage. Which of the following is NOT true?

The insurer will issue a conditional coverage

An insured does not have to pay coinsurance or deductibles on a full-series mouth x-ray, but does have to pay a deductible to get his cavities filled. Which dental plan does he have?

nonscheduled

Which of the following describes self-insurance?

A business engages in the same types of activities as a commercial insurer and deals with its own risks.

Insurers must report or list all appointments and all terminations of appointments to what authority?

Commissioner

Which of the following provisions must be included on the first page of a Medicare supplement policy, which states the insurer's right to change premium amounts?

Continuation provision

After a year of receiving disability income benefits, the insured notices that her monthly benefit has increased slightly. What rider does the policy most likely have that would cause this?

Cost of Living Adjustment Rider (COLA)

Which rider, when added to a disability income policy, provides for changes in the benefits payable based on changes in the consumer price index?

Cost of living adjustment rider

A newborn is automatically covered under his/her parents' health insurance policy for 60 days. After that point, the coverage may be cancelled, unless within one year after the birth of the child the insured makes all past due payments plus interest applied at the rate of

5.5% per year.

Once an individual is licensed as an insurance producer for life or accident and health insurance, how many hours of training must the producer complete initially to sell long-term care insurance?

8 hours

What is the minimum number of employees that a small employer must have?

2

A claim is considered overdue if NOT paid within how many days after the insurer receives written notice?

30 Days

How long does the free look period last for a Medicare supplement policy?

30 days

What is the maximum number of employees that a small employer can have?

50

Benefit periods for individual short-term disability policies will usually continue from

6 months to 2 years.

Every disability insurance policy with weekly premiums must contain a provision for a grace period lasting at least

7 days

All of the following statements about Medicare supplement insurance policies are correct EXCEPT

They cover the cost of extended nursing home care.

When must the "Wisconsin Guide for Health Insurance for People with Medicare" pamphlet be issued?

With every policy solicitation

All of the following statements concerning Medicaid are correct EXCEPT

Medicaid is a state funded program that provides health care to persons over age 65, only.

An insured severely burns her hand, but is not classified as disabled. Which of the following types of coverage would cover at least a portion of the insured's medical expenses?

Medical reimbursement benefit

OBRA requires which disease to be covered by an employer for 30 months before Medicare becomes the primary mode of coverage?

End-Stage Renal Failure

The authority granted to an agent through the agent's contract is referred to as

Express Authority

A policyowner is reading a statement on the first page of his health insurance policy, which says "this is a limited policy." What is the name of this statement?

Limited Policy Notice

The Interstate Insurance Product Regulation Compact is a contract between

Member States

An agent who includes a statement or omits a statement which, when taken in context of the whole presentation, may tend to mislead or deceive the persons addressed has committed

Misrepresentation

A license applicant's trustworthiness and competence will be determined by all of the following EXCEPT

Personal testimonies from previous co-workers and managers.

An underwriter may reject an application for health insurance if the rejection is based upon which of the following?

Prescription usage

A long-term care shopper's guide must be presented at what point?

Prior to the time of application

Under which provision can a physician submit claim information prior to providing treatment?

Prospective Review

Following a career change, an insured is no longer required to perform many physical activities, so he has implemented a program where he walks and jogs for 45 minutes each morning. The insured has also eliminated most fatty foods from his diet. Which method of dealing with risk does this scenario describe?

Reduction