mass exam 3
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 (days 21 to 100 require daily copayment)
COBRA applies to companies with how many employees
20 or more
Nonqualified distributions from an MSA are included in the employee's gross income and subject to a penalty tax of
20%
A policy deemed to be approved by the commissioner if it has been on file for at least how many days
30 days
under COBRA, for events such as death of employee, or divorce, how long is the period for dependents
36 months
Health benefits plans are prohibited from including waiting periods that exclude coverage for more than how many months
4 months
terminated employees under COBRA must exercise benefits within how many days
60 days
cost of living adjustment
A disability insurance provision to increase monthly benefits
Estoppel
A legal impediment to denying a fact or restoring a right that has been previously waived.
Substandard Risk
An applicant or insured who has a higher than normal probability of loss, and who may be subject to an increased premium.
Conformity with State Statutes
Any policy provision that is in conflict with state statutes in the state where the insured lives at the time the policy is issued is automatically amended to conform with the minimum statutory requirements of that state
Under a Key Person disability income policy, premium payments
Are made by the business and are not tax-deductible.
Custodial Care
Care that is rendered to help an insured complete his/her activities of daily living.
Group disability income insurance premiums paid by the employer are
Deductible by the employer as an ordinary business expense.
Attending Physician's Statement (APS)
Designed to obtain more specific information about a particular medical problem revealed in the application or during the medical examination
An insured has medical insurance coverage through 2 different providers, both covering the same expenses on an expense-incurred basis. Neither company knows in advance that the insured has coverage through any other insurers. The insured submits a claim to both insurers. How should the claim be handled?
Each insurer should pay a proportionate share of the claim
retrospective review
Employers and insurers can evaluate the utilization review process and the effectiveness of the professionals involved in large claims. These reviews include hospital bill audits.
Which entity must approve all Medicare supplement advertisements?
Insurance Commissioner or Director
Buy-sell policy (benefits)
received income tax free
Paul is a producer in Vermont and wants to become a producer in Massachusetts. The Department will waive certain examination requirements, provided that Vermont would waive these same requirements if a Massachusetts producer sought licensure in Vermont. What term is used to describe this phenomenon?
reciprocity
Preferred Risk
reflect a reduced risk of loss and are covered at a reduced rate (nonsmokers)
Standard Risk
reflect average exposures and may be insured at standard rates and premiums
Waiver of Premium Rider
should the owner be disabled and cant earn an income, after 6 months, all premiums will be paid by the insurer during the disability period; After 6 months, the premiums will be repaid
concurrent review
the insurance company will monitor the insured's hospital stay
Provided they are of a certain age, residents of Massachusetts are required to maintain minimum creditable coverage. What age?
18
for any qualifying event under COBRA, coverage us extended up to how many months
18 months
The relation of earnings to insurance provision allows the insurance company to limit the insured's benefits to his/her average income over what period of time?
2 years
An insured buys an individual long-term care policy and is not satisfied with the provisions. Within how many days will the insured be able to return the policy for a full premium refund?
10 days
Accidental Bodily Injury
Unplanned, unforeseen traumatic injury to the body.
The Pregnancy Discrimination Act specifically prohibits pregnancy discrimination by employers with the minimum of how many employees?
15
Yearly Wellness Visit (Part B)
preventative visit available during first 12 months
Which statement regarding insurable risks is NOT correct? a)An insurable risk must involve a loss that is definite as to cause, time, place and amount. b)Insureds cannot be randomly selected. c)Insurance cannot be mandatory. d)The insurable risk needs to be statistically predictable.
Insureds cannot be randomly selected. (Granting insurance must not be mandatory, selecting insureds randomly will help the insurer to have a fair proportion of good risks to poor risks. All other statements are true.)
Which entity has the authority to make changes to an insurance policy?
Insurer's executive officer
Reciprocity licensure
Massachusetts permits nonresident licensure for all nonresidents of the state whose home states issue a similar nonresident license to Massachusetts residents living in that state
outpatient treatment of mental illness (part b)
Medicare covers outpatient treatment of an approved condition in a doctor's office or other health care provider's office or hospital outpatient department (inpatient is covered under Part A)
Home Health Visits (part b)
Medicare will pay for home health services as long as these services are recommended by the insured's doctor and the insured is eligible.
Premium payments for personally-owned disability income policies are
Not tax deductible.
Under most dental plans, what limitations are posed for denture replacement?
Once every 5 years
Outpatient Hospital Services (part b)
Part B covers outpatient hospital services received for diagnosis and treatment, such as care in an emergency room, outpatient clinic, or a hospital
Medical Reimbursement Benefit
Pays medical expenses for nondisabling injuries.
All of the following are covered by Part A of Medicare EXCEPT )Physician's and surgeon's services. b)In-patient hospital services. c)Post-hospital nursing care. d)Home health services.
Physician's and surgeon's services.
A guaranteed renewable health insurance policy allows the
Policyholder to renew the policy to a stated age, with the company having the right to increase premiums on the entire class.
insurance information and privacy act
Sets up procedures for consumer reporting agencies. does not apply to information collected from public records of a governmental authority
Notice Regarding Replacement
Signed by both the applicant and the producer. must inform the applicant of the 30 day free look provision of the replacing policy
If an insurer becomes insolvent, who would pay benefits to policyholders?
The Guaranty Association
Apparent Authority
The appearance or the assumption of authority based on the actions, words, or deeds of the principal or because of circumstances the principal created.
Aleatory Contract
The exchange of value is unequal.
An insured purchased a noncancellable health insurance policy 1 year ago. Which of the following circumstances would NOT be a reason for the insurance company to cancel the policy? a)The insured is in an accident and incurs a large claim. b)The insured does not pay the premium. c)The insured reaches the maximum age limit specified in the policy. d)Within two years of the application, the insurer discovers a misrepresentation.
The insured is in an accident and requires large claim.
Prospective Review
The physician can submit claim information prior to providing treatment to know in advance if the procedure is covered under the insured's plan and at what rate it will be paid.
Which of the following provisions must be included on the first page of a Medicare supplement policy, which states the insurers right to change premium amounts?
The renewal provision, also known as continuation provision, must be included on the first page of medicare supplement policies.
In insurance policies, contract ambiguities are automatically ruled in the favor of the insured. What privilege does the insurer have in order to balance this?
The right to determine the wording of a policy
Accidental Means Clause
This clause will cover accidents only if the cause is unintentional and unforeseen
A nonresident producer who moves from one state to another state or a resident producer who moves from the commonwealth to another state must file a change of address and provide certification from the new resident state
Within 30 days of the change of legal residence
If a producer has administrative action taken against his license, he must report such action
Within 30 days of the final disposition on such action.
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
What is the amount a physician or supplier bills for a particular service or supply?
actual charge
Twisting
agent persuades an insured to cancel, lapse, or switch policies, even when it's to the insured's disadvantage.
Implied Authority
an agent's authority to do things not specifically authorized in order to carry out express authority
Declined Risks
applicants who are rejected
Which of the following entities is responsible for paying the producer's appointment renewal fee?
appointing insurer
If during the underwriting process an insurer obtains personal information about an applicant from the applicant, when must the insurer provide notice of its information practices?
at the time of policy delivery
Doctor Services (Part B)
covered by part B. includes surgical services, diagnostic tests and x-rays, medical supplies furnished in doctors office, and office nurse service.
What is the difference between the Medicare approved amount for a service or supply and the actual charge?
excess charge
An insurance company has published a brochure that inaccurately portrays the advantages of a particular insurance policy. What is this an example of?
false advertising
What option allows the insured to periodically increase benefit levels without providing evidence of insurability?
guarantee of insurability
A new employee who meets HIPAA eligibility requirements must be issued health coverage on what basis?
guaranteed
Guarenteed Insurability Rider (GIR)
protects the insureds right to buy more coverage in the future without the need to prove good health
Insurers may change which of the following on a guaranteed renewable health insurance policy?
rates by class
Reinstatement
if premium has not been paid by end of grace period, the policy will lapse. coverage automatically reinstated if not refused within 45 days from the date the conditional receipt was issued. accidents covered immediately.
coordination of benefits provision
in group health insurance is designed to prevent overinsurance and the duplication of benefits if one person is covered under more than one group health insurance plan.
cost-saving services (aka case management provisions) include
include services like preadmission testing, second opinions regarding surgery, preventative care, risk sharing
the outline of coverage must provide
information about the insurance company, the policy number, important features of the policy, and explain the right to return the policy for a refund
Adhesion
insured has little to say about policy provisions
In the event of loss, after a notice of claim is submitted to the insurer, who is responsible for providing claims forms and to which party?
insurer to insured
The section of a health policy that states the causes of eligible loss under which an insured is assumed to be disabled is the
insuring clause
Which of the following is the basis for a claim against an insurance policy?
loss
A health insurance plan which involves financing, managing, and delivery of health care services and involves a group of providers who share in the financial risk of the plan or who have an incentive to deliver cost effective service, is called
managed care plan
Part B financed by
monthly premiums paid by insured, and federal government
Under the Fair Credit Reporting Act, individuals rejected for insurance due to information contained in a consumer report
must be informed of the source of the report
medical savings accounts are only available to groups of how many employees?
no more than 50
Bethany studies in England for a semester. While she is there, she is involved in a train accident that leaves her disabled. If Bethany owns a general disability policy, what will be the extent of benefits that she receives?
none
The Commissioner may issue a temporary insurance producer license without requiring an examination for a period
not to exceed 180 days
An insured has health insurance that covers them at work and at home. This policy was written on what basis?
occupational
prescription drugs (part b)
only medicines that are administered in a hospital outpatient department under certain circumstances. otherwise, insured under part B will have to pay 100%, unless covered by part D.
Part A financed by
payroll taxes (FICA)
community rating
premiums based on overall claims experience experience of the insurance company (individual policy)
After the elimination period, a totally disabled insured qualified and started receiving benefits from his disability income policy that has a waiver of premium rider. What will most likely happen to the premiums paid into the policy during the elimination period?
premiums will be refunded
Experience Rating
the premiums are determined by the experience of this particular group as a whole - helps employers with low claims because they get lower premiums (group policies)
Which of the following is true regarding benefits paid to disabled employees?
they may be subject to taxation if the premium was paid by the employer