Wisconsin Accident and Health Insurance Exam 2

Emergency health care coverage for Medicare enrollees traveling abroad is Excluded from a Medicare Supplement. A core benefit under a Medicare Supplement. A Medicare Supplement additional benefit. A Medicare Part D benefit.

A Medicare Supplement additional benefit.

Which of the following describes coverage for the Medicare Part B coinsurance? Only a Long-term care policy will cover Medicare Part B coinsurance. A Medicare Supplement optional benefit. A Medicare Supplement core benefit. Medicare Part B does not require a coinsurance so no additional coverage is needed.

A Medicare Supplement core benefit.

A health plan offered by private insurance companies is Social Security. Medicaid. Medicare. A Medicare Supplement.

A Medicare Supplement.

An applicant submits an accident and health insurance application where an investigative consumer report is used in the underwriting process. Which of these statements is true? Applicant can determine which items in the report to leave out. Insurer can obtain a copy of this report without the applicant's knowledge. Fee for the report is typically paid by the applicant. Applicant has a right to receive a copy of the report.

Applicant has a right to receive a copy of the report.

In what situation could an insurance policy's coverage be modified? Applicant is a preferred risk. Applicant is a substandard risk. Applicant is a standard risk. Applicant is uninsurable.

Applicant is a substandard risk.

Which of the following is considered a Limited accident and health plan? HMO. PPO. Cancer plan. Major medical plan.

Cancer plan.

Which of the following is NOT an allowable exclusion for long-term care insurance policies? Self-inflicted injuries. Acute care. Custodial care outside the U.S. Care for incurable conditions.

Care for incurable conditions.

What is a Pap test designed to detect? Cervical cancer. Prostate cancer. Oral cancer. Breast cancer.

Cervical cancer.

Which of the following does NOT meet the requirements of "skilled nursing care"? Must be ordered by a doctor. Must require daily care. Must be provided exclusively in a hospital. Must be provided by skilled medical practitioners.

Must be provided exclusively in a hospital.

Medicaid will pay for nursing home expenses under what condition? Must have permanent kidney failure. Must be age 65 or older. Must be receiving Social Security disability benefits. Must have financial need.

Must have financial need.

Which of these is NOT used as selection criteria in the underwriting process of an accident and health insurance application? Credit report. National origin. Age of applicant. Sex of applicant.

National origin.

Specialty care is provided by which of the following health maintenance organization (HMO) providers? Neurologist. HMO administrator. HMO director. Gatekeeper.

Neurologist.

Medicare Supplement insurance requires an individual to be at least how old for open enrollment? 59 1/2 years old. 65 years old. 70 1/2 years old. No minimum age.

No minimum age.

The disability income policy most likely to have been issued on a substandard basis is Non-cancelable with a 60-day elimination period. Conditionally renewable. Non-cancelable with a health condition exclusion rider. Guaranteed renewable with an inflation rider.

Non-cancelable with a health condition exclusion rider.

Tim is covered by an accident and health insurance policy that may not be changed in any way by the insurer up to a stated age, as long as the premiums are paid. What type of policy is this? Optionally renewable. Noncancelable. Guaranteed renewable. Conditionally renewable.

Noncancelable.

Which of the following health insurance plans charges a premium that cannot be increased? Guaranteed renewable. Cancelable. Noncancelable. Conditionally renewable.

Noncancelable.

A major medical expense policy typically does NOT Contain a deductible. Have a high limit of coverage. Contain a coinsurance provision. Pay surgeon fees on a first-dollar basis.

Pay surgeon fees on a first-dollar basis.

Which type of deductible must be satisfied again for each illness or accident in a major medical plan? Specific-cause. Per-cause. All-cause. Comprehensive-cause.

Per-cause.

Under a long-term care inflation rider, the benefit levels Periodically increase without proof of insurability. Periodically decrease without proof of insurability. Periodically increase with proof of insurability. Periodically decrease with proof of insurability.

Periodically increase without proof of insurability.

Which would NOT be a location where skilled nursing care is provided? Hospital. Custodial care facility. Nursing home. Personal residence.

Personal residence.

A health insurance applicant is notified that a physical examination is required. Which of the following statements is correct? Physical examinations are performed at the expense of the applicant. Physical examinations are performed at the expense of the insurer. All applicants for group health insurance require a physical examination. All applicants for health insurance do not require a physical examination.

Physical examinations are performed at the expense of the insurer.

Which of these plans allow a participant to choose either a network or non-network provider at the time when medical care is needed? HMO. Medicare Supplement. Point-of-service. Limited benefit.

Point-of-service.

The standard provisions of an accident and health insurance policy require that the Policy, endorsements, and attached papers constitute the "entire contract". Policy summary, conditional receipt, and initial premium constitute the "entire contract". Change of occupation provision is mandatory. Grace period be no shorter than 60 days.

Policy, endorsements, and attached papers constitute the "entire contract".

A disability income insurance policy was recently issued with a rating. What does this mean? Policyowner will be charged an additional premium. Policy will have specific illnesses excluded from coverage. Policyowner will be charged a reduced premium. Policy will have a longer waiting period.

Policyowner will be charged an additional premium.

Tim is in need of surgery. Before being hospitalized, he is referred to an outpatient clinic for diagnostic tests. What is this an example of? Pre-admission testing. Capitation. Mandatory second opinion. Concurrent review.

Pre-admission testing.

Patrick purchased a long-term care policy. He has a health condition for which medical treatment was recommended by a physician within 6 months prior to the policy's effective date. This condition is called a(n) Antecedent condition. Pre-existing condition. Hazardous condition. Grandfathered condition.

Pre-existing condition.

The agreement in which hospitals and physician groups in a specific area contract with an insurance company to provide medical care at predetermined costs is Preferred Provider Organization (PPO). Health Maintenance Organization (HMO). Designated Provider Organization (DPO). Professional Service Organization (PSO).

Preferred Provider Organization (PPO).

Where is the difference between a standard risk and a substandard risk reflected? Backdating. Coverage is not offered. Premium charges. Back-end charges.

Premium charges.

A Guaranteed Renewable provision allows Discrimination of individuals who have an increased loss experience. Premiums that may not be increased beyond contractual requirements. Premiums which can only be increased per rate class. Cancellation of the policy at the insurer's discretion.

Premiums which can only be increased per rate class.

Home health care benefits typically do NOT include coverage for Nursing care. Wheelchairs. Physical therapy. Prescription medication.

Prescription medication.

Karen is a health maintenance organization (HMO) subscriber. Who provides all of her preventative and routine care? Primary care physician Provider specialist. Preventative coordinator. HMO director.

Primary care physician.

A pre-existing condition exclusion in an accident and health insurance policy pertains to Prior insurance coverage. Prior financial matters. Prior health matters. Prior occupations.

Prior health matters.

Which of the following does NOT fall under "hospital care" in a typical health maintenance organization (HMO) plan? Private duty nursing. Inpatient X-rays. Inpatient mental health care. Inpatient lab services.

Private duty nursing.

Alan is an enrollee of a health maintenance organization (HMO) which uses a gatekeeper system. If there ever comes a time when he needs emergency health services, what should he do? Receive permission from the primary physician to begin treatment. Call the HMO to verify coverage. Proceed to the nearest emergency room. Contact the HMO for a listing of approved providers.

Proceed to the nearest emergency room.

When a producer submits an application that discloses personal information regarding the applicant, who supplies the privacy notice? Producer. Insurer. Underwriter. Fiduciary.

Producer.

A Medicare Supplement policy is required to do which of the following? Provide a 10 day free-look period. Provide a 20 day free-look period. Provide a 30 day free-look period. Provide a 60 day free-look period.

Provide a 30 day free-look period.

Which of the following is NOT a reason the government provides insurance? Stimulate economic development. Reduce fraudulent claims. Ensure social needs are being met. Increase availability of health coverage.

Reduce fraudulent claims.

Omar is covered by a disability income policy. He is hurt while performing an occupation more hazardous than the occupation listed in his policy. The policy's change of occupation provision will have what effect? Increase the benefit level. Reduce the benefit level. Increase the premiums. Decrease the premiums.

Reduce the benefit level.

Which of the following is NOT included as a hospice benefit under a major medical plan? Home-based services. Counseling. Rehabilitation. Pain management.

Rehabilitation.

Which of the following is NOT a basic underwriting action for accident and health insurance? Excluding a particular health condition from coverage. Removing uniform policy provisions. Declining applications. Issuing a policy at standard issue.

Removing uniform policy provisions.

All parts of the Medicare program (except for public information and enrollment) are administered by which federal agency? The ACA. The Social Security Administration. The Department of Homeland Security. The Centers for Medicare and Medicaid Services.

The Centers for Medicare and Medicaid Services.

Which statement concerning the Entire Contract provision in an individual accident and health insurance policy is TRUE? The agent can waive policy provisions and change the policy with the insurer's consent. The agent has the authority to waive the policy's provisions under certain conditions. The agent has the authority to change the policy under certain conditions. The agent doesn't have the authority to change the policy or waive its provisions.

The agent doesn't have the authority to change the policy or waive its provisions.

In order to contribute to a Health Savings Account (HSA) The applicant must have no sickness & accident coverage. The applicant must be enrolled in a High Deductible Health Plan (HDHP). The applicant must be at least 55 years of age. The applicant must be at least 65 years of age.

The applicant must be enrolled in a High Deductible Health Plan (HDHP).

Why might it be beneficial for an employee to purchase private disability income insurance for workplace injuries when he/she is already covered by worker's compensation? Loss of income that results from a workplace injury is not covered by worker's compensation. Worker's compensation claims require a lengthy elimination period before benefits are paid. Worker's compensation benefits are taxable and additional coverage needs to be purchased to offset the tax. The benefits arising from a worker's compensation claim could be inadequate to replace the loss of income.

The benefits arising from a worker's compensation claim could be inadequate to replace the loss of income.

Fee-for-service is a method of administering health insurance benefit payments in which The insurer is reimbursed directly. The cost of each service is bundled into one payment. The cost of each service is scheduled. The insurer pays for services through a voucher system.

The cost of each service is scheduled.

K is an agent who takes an application for individual accident and health insurance and accepts a check from the client. He submits the application and check to the insurance company, however the check was never signed by the applicant. If the application is approved, when will coverage be effective? The date the sales appointment was made. The date the application was submitted to the insurance company. The date of application. The date the producer delivered the policy, collected the initial premium, and obtained a good health statement from the insured.

The date the producer delivered the policy, collected the initial premium, and obtained a good health statement from the insured.

The insured's consideration given for a health insurance policy is The first premium payment and the application. The initial premium payment only. The application. The initial premium and an investigative report.

The first premium payment and the application.

Who may terminate coverage under a cancelable health insurance policy? The insured only. The insurer only. The insurer or the insured. An officer of the insurer.

The insurer or the insured.

James is covered with health insurance by two different insurers. The "insurance with other insurers" provision in an individual health insurance policy allows an insurer to pay benefits to the insured on a pro-rata basis when The policy's maximum lifetime benefit level has been paid. The policy is beyond the incontestable period. The insurer was not notified prior to the claim that the insured has other health coverage. The policy is beyond the free-look period.

The insurer was not notified prior to the claim that the insured has other health coverage.

Which of these is a typical result of a concurrent review? The deductible amount is increased. The length of time spent in the hospital is monitored. The insured's premiums usually increase. The coinsurance is waived.

The length of time spent in the hospital is monitored.

Dan has a major medical expense policy with a $200 deductible and an 80/20 coinsurance provision. He incurs covered medical expenses of $100 in November and $400 in January. Under the carryover provision, what will the insurer pay? $200. $210. $220. $240.

$240. The Carryover provision permits expenses incurred during the last 3 months of the calendar year to be carried over into the new year if needed to satisfy the deductible for the next year. In this case, the insurer would have to pay $240. ($100 + $400=$500 covered medical expenses; $500 - $200 deductible = $300. $300 X 80% = $240 payable by insurer)

An insured files for an accident and health insurance policy claim eight days after the premium due date. The benefit payable is $500 and the overdue premium is $200. Assuming that the policy pays on a first-dollar basis and contains the unpaid premium provision, how much will the insurer pay? $0. $200. $300. $500.

$300.

Larry has a Major Medical Expense policy for his family with a $1,000 per family/per year deductible and an 80/20 coinsurance provision. If Larry's family files four claims of $400, $800, $100, and $700 in one year, how much will the insurance company pay? $500. $800. $1,000. $1,200.

$800. In this situation, the insurer will pay $800. $400 + $800 + $100 + $700 = $2,000. The insurance company pays 80% of $1,000 (outstanding balance after deductible is paid), or $800.

An individual is insured under a major medical plan with a $1,000,000 lifetime benefit. The plan has a $500 deductible and an 80% coinsurance. If the insured suffers a $50,500 medical expense during the calendar year, what is the remaining lifetime benefit? $950,000. $960,000. $989,500. $1,000,000.

$960,000 $50,500 - $500 deductible = $50,000. $50,000 x 80% = $40,000. $1,000,000 lifetime benefit - $40,000 = $960,000 remaining.

Periodic health claim payments MUST be made at least Monthly. Weekly. Daily. Annually.

Monthly.

How long is individual medical expense insurance normally written for? 1 year. 2 years. 3 years. 4 years.

1 year.

Medicare will cover a maximum of how many days per benefit period in a skilled nursing facility? 10 days. 30 days. 60 days. 100 days.

100 days.

Mary is the sole proprietor of her business and has a family health plan. She would like to deduct the premiums from her taxes. What percentage of her premiums are tax deductible? 0% 50% 75% 100%

100%

Which of the following best describes the tax treatment of medical expense policies for the self-employed? 100% of medical expense plan premiums are tax deductible. 50% of medical expense plan premiums are tax deductible. 7.5% of medical expense plan premiums are tax deductible. 0% of medical expense plan premiums are tax deductible. 2

100% of medical expense plan premiums are tax deductible.

What is the maximum Social Security Disability benefit amount an insured can receive? 50% of the insured's Primary Insurance Amount (PIA). 75% of the insured's Primary Insurance Amount (PIA). 100% of the insured's Primary Insurance Amount (PIA). 100% of the insured's Primary Insurance Amount (PIA) minus any monies received from a retirement plan.

100% of the insured's Primary Insurance Amount (PIA).

Individuals seeking Social Security disability income benefits must have a disability that will eventually lead to death, or be expected to last at least 3 months. 6 months. 9 months. 12 months.

12 months.

Part A Medicare includes coverage for all of the following services EXCEPT First 60 days of hospitalization. 120 days of Skilled Nursing Facility care. Hospice care. Inpatient mental health care limited to 190 days in a lifetime.

120 days of Skilled Nursing Facility care.

Mary has a Health Savings Account (HSA). Distributions that she has made for anything other than qualified medical expenses are considered taxable and subject to a penalty of 10%. 20%. 30%. 50%.

20%.

An insured must notify an insurer of a medical claim within how many days after an accident? 10. 20. 30. 40.

20.

Social Security disability income requirements state that in order to become fully insured on a permanent basis, you must have worked in a covered occupation for 10 quarters. 20 quarters. 30 quarters. 40 quarters.

40 quarters.

What is the MAXIMUM number of employees an employer may have for qualified medical savings accounts? 20 employees. 30 employees. 40 employees. 50 employees.

50 employees.

At what age do most people become eligible for Medicare? 59 1/2. 62. 65. 72.

65.

After an applicant reads and signs an insurance application, he/she should be conscious of the fact that A false statement could lead to loss of coverage. Premium refunds are not allowed. The policy is guaranteed to be issued. The premium quoted by the agent is final.

A false statement could lead to loss of coverage.

Medicare can be described as A supplemental income source for individuals over the age of 65 or permanently disabled. A state health program for individuals over the age of 65 or permanently disabled. A federal health program for individuals with financial need. A federal health insurance program for individuals over the age of 65 or permanently disabled.

A federal health insurance program for individuals over the age of 65 or permanently disabled.

The coinsurance for skilled nursing facility services covered by Medicare after the 100% Medicare coverage ends is 15% of the approved amount. 30% of the approved amount. A percentage of the approved amount. A flat dollar amount per day.

A flat dollar amount per day.

Which of the following best describes a point-of-service (POS) plan? A plan which combines medical health care with long-term care coverage. A plan which combines indemnity plan features with those of an HMO. A plan which does not allow treatment with non-network providers. A plan which operates like a PPO plan without a gatekeeper.

A plan which combines indemnity plan features with those of an HMO.

What does the term "field underwriting" refer to in the health insurance industry? A producer's contact with the applicant. The interaction of an underwriter with the applicant. The medical reports issued by the MIB. An insurer conducting an investigative report.

A producer's contact with the applicant.

What is normally the consequence for NOT obtaining preadmission certification prior to receiving inpatient medical care? A reduction in benefits. A delay in the payment of benefits. A cancellation of coverage. A taxation of benefits.

A reduction in benefits.

What is a "functional assessment" for long-term care benefits? An assessment of the insurer's financial solvency. A review of the insurer's ability to pay long-term care benefits. A review of the insured's ability to perform the activities of daily living. An assessment of the quality of care given in a long-term care facility.

A review of the insured's ability to perform the activities of daily living.

What do Limited accident and health policies normally cover? A specific illness or event. A specific age group. A specific income group. A specific geographical location.

A specific illness or event.

An attending physician's statement is best described as An MIB report. A physician's report from an insurance exam. Medical information on the application. A summary of medical history from the physician listed on the application.

A summary of medical history from the physician listed on the application.A summary of medical history from the physician listed on the application.

Disability income insurance normally excludes coverage for disabilities that arise from Automobile accidents. Injuries sustained while traveling abroad. Occupational injuries. Active military duty.

Active military duty.

In long-term care insurance, what is an "ADL"? Advocates of daily living. Approved dollar limits. Activities of daily living. Accepted doctor lists.

Activities of daily living.

Which of the following is NOT covered by a comprehensive long-term care policy? Custodial care. Acute care. Physical therapy. Skilled nursing care.

Acute care.

Which of the following statements accurately describes the "time limit on certain defenses"? After a stated period of time, claims cannot be denied due to material misrepresentation on the application. All claims can be disputed after two years. An insured cannot file a lawsuit within 90 days of the claim being filed. The right to return an accident and health policy must be within 10 days of policy delivery.

After a stated period of time, claims cannot be denied due to material misrepresentation on the application.

What is a major difference between private commercial insurers and HMO's? An HMO pays claims on a fee-for-service basis. A private commercial insurer typically has fewer health provider choices. An HMO combines medical care delivery and funding in one organization. A private commercial insurer only offers individual coverage.

An HMO combines medical care delivery and funding in one organization

Rick is a disabled worker receiving Social Security benefits. What benefits are his wife and dependent children eligible for? No benefits. Spouse is eligible for an income benefit but the children are not. An income benefit which is a percentage of his primary insurance amount. An income benefit which equals his entire primary insurance amount.

An income benefit which is a percentage of his primary insurance amount.

Select the appropriate response Which of the following situations would a medical exam NOT be required for an individual health insurance applicant? Applicant was recently hospitalized. Applicant has not had a physical exam in a number of years. Applicant's family members have a history of cancer. Applicant has no prior health insurance.

Applicant's family members have a history of cancer.

Julie is in need of assistance with one or two activities of daily living. She may be eligible for a(n) Respite care facility. Hospice facility. Assisted living facility. Intermediate care facility.

Assisted living facility.

What are reasonable and customary charges for health insurance primarily based on? Average charges as determined by the NAIC. Average charges as determined by actuarial tables. Average charges within a geographic region. Average charges within the United States.

Average charges within a geographic region.

In long-term care insurance, what is the length of time for which claims will be paid? Benefit period. Free-look period. Grace period. Elimination period.

Benefit period.

Which of these statements regarding Major Medical Expense insurance is NOT true? Benefits are paid typically after the coinsurance provision has been satisfied. Policies normally have a high maximum benefit. Policies typically include a deductible. Benefits are paid on a capitation basis.

Benefits are paid on a capitation basis.

The Change of Occupation provision in a Disability Income policy states that, in the event the insured changes to a less hazardous occupation, which of the following may apply? Benefits will remain the same in the event of a covered claim. Premiums cannot be adjusted. Benefits can be increased in the event of a covered claim. Benefits can be reduced in the event of a covered claim.

Benefits can be increased in the event of a covered claim.

Tim had an on-the-job accident and collects benefits from his individual disability income policy. Which factor could possibly reduce these benefits? State and federal income taxes. Benefits he receives from workers compensation. Total household income. Assistance he receives from friends and family.

Benefits he receives from workers compensation.

A preferred provider plan and an indemnity plan are similar in what way? Only select providers may be used. Both pay on a fee-for-service basis. Any provider may be used. Both operate on a prepaid basis.

Both pay on a fee-for-service basis.

An accident and health insurer has just received written proof of loss from one of its insureds. The insured must now wait 60 days before Submitting another claim. Bringing legal action against the insurer. The insurer will pay the claim. Purchasing more insurance from this insurer.

Bringing legal action against the insurer.

The guarantee of insurability option provides a long-term care policyowner the ability to Buy additional coverage at a later date. Add the insured's spouse at a later date. Pay the same premium for life. Cancel the policy at anytime.

Buy additional coverage at a later date.

A Health Reimbursement Arrangement MUST be established With employee funding. With other employer-sponsored benefit plans. By the employer. Only during specific open enrollment periods.

By the employer.

A policyowner suffers a covered accident and health insurance loss on June 30 and submits the proof of loss to the insurer July 10. If the policyowner cancelled the coverage on July 2, how will the insurance company handle the claim? Insurer does not have to pay the claim. Only a percentage of the claim will be paid. Claim must be paid after proof of loss is received. Claim will be denied.

Claim must be paid after proof of loss is received.

Which of the following statements is true regarding accident and health insurance claims that reimburse on an indemnity basis? No proof of loss is needed. Claims can be sent directly to the insured. Claims are required to be sent to the health provider. No claim form is needed.

Claims can be sent directly to the insured.

Chris has a single major medical contract which covers all medical expenses. His plan is considered to be Comprehensive. Supplemental. Limited. Basic.

Comprehensive.

What must be given to an accident and health insurance applicant when the producer receives an application and the initial premium? Producer's report. Conditional receipt. Commission disclosure. Good health statement.

Conditional receipt.

An accident and health insurance policy's premium requirements are set forth in which of the following provisions? Insurance clause. Entire Contract clause. Consideration clause. Premium mode.

Consideration clause.

Which report contains information regarding an individual's general reputation and credit standing? Credit report. Consumer report. MIB report. Agent's report.

Consumer report.

What does a Mandatory Second Surgical Opinion provision provide to an employer-paid health insurance plan? No pre-existing condition exclusions. Higher employee retention. Containment of the employer's premium cost. Increase in surgical procedures.

Containment of the employer's premium cost.

Select the appropriate response In what situation would disability income insurance premiums be a deductible expense? Partnership paying for group disability income coverage for the partners. Corporation paying for group disability income coverage for its employees. Individual paying for his/her own individual disability policy. Parent paying for a child's individual disability policy.

Corporation paying for group disability income coverage for its employees.

Reductions in coverage are one feature of _______ in Health insurance policies. Optional provisions. Mandatory provisions. Cost containment. The insuring clause.

Cost containment.

Reductions in coverage are one feature of _______ in health insurance policies. Optional provisions. Mandatory provisions. Cost containment. The insuring clause.

Cost containment.

Which statement is true about a permanent disability under workers compensation coverage? Employee is expected to return to work within 6 months. Coverage includes nonoccupational injuries. Employee is expected to make a full recovery. Coverage excludes nonoccupational injuries.

Coverage excludes nonoccupational injuries.

Linda is covered with long-term care insurance and has early-stage Alzheimer's. She is still able to reside in her home while receiving primary care, as opposed to moving into a nursing home. All of the following long-term benefits encourage home health care EXCEPT Custodial care. Home health care. Adult day care. Respite care.

Custodial care.

What type of doctor-ordered care assists an individual with performing basic daily activities such as bathing, dressing, and eating? Custodial care. Respite care. Family care. Domestic care.

Custodial care.

The amount of a covered loss to be paid by the insured before a major medical expense policy begins to pay is called the Out-of-pocket expense. Coinsurance percentage. Deductible amount. Usual, customary, and reasonable charges.

Deductible amount.

Which of these is NOT an underwriting responsibility of an insurance producer? Asking relevant questions concerning an applicant's avocations. Requesting an attending physician's report (APR). Ordering an inspection report. Determining the final rate classification.

Determining the final rate classification.

Health Maintenance Organization (HMO) wellness programs may include each of the following EXCEPT Stress reduction. Routine physicals. Smoke cessation programs. Diagnostic testing services.

Diagnostic testing services.

Select the appropriate response To which of the following group plans do HIPAA rules NOT apply? PPOs. Disability income. HMOs. Major Medical.

Disability income.

Which of these noncontributory group plans would a claim likely result in the payment of federal income taxes? Accidental death. Blanket health. Major medical. Disability income.

Disability income.

An HMO prescription drug plan is generally characterized by Generic drugs only. Annual deductibles. Drugs dispensed through participating pharmacies. Drugs dispensed through online pharmacies.

Drugs dispensed through participating pharmacies.

When dealing with long-term care coverage, which of the following are classified as ADLs? Reading, writing, learning. Occupation, income, insurability. Age, height, weight. Eating, bathing, dressing, and mobility.

Eating, bathing, dressing, and mobility.

The benefit period of Medicare Part A begins on the first day the insured Notices symptoms. Enters a hospital. Becomes eligible for Medicare. Is diagnosed of an illness.

Enters a hospital.

Which of the following health insurance provisions requires that the application becomes part of the policy? Consideration clause. Insuring clause. Entire Contract clause. Application clause.

Entire Contract clause.

The difference between a doctor's actual charges and the amount approved by Medicare is referred to as a(n) Usual, reasonable, and customary amount. Excess charge. Deductible. Surplus fee.

Excess charge.

Terry suffers an injury at his workplace which is covered by workers compensation. Terry also has a medical expense insurance policy. Under medical expense insurance policies, losses that are covered by workers compensation are typically Excluded from coverage. Partially covered. Covered, but requiring a higher deductible and copay. Subject to age restrictions.

Excluded from coverage.

Employer-paid qualified long-term care insurance premiums are typically Deducted from the employee's net income. Included in the employee's gross income. Included as a dividend to the employee. Excluded from the employee's gross income.

Excluded from the employee's gross income.

Long Term Care policies will usually pay for eligible benefits using which of the following methods? Delayed. Fee for service. Expense incurred. Respite.

Expense incurred.

Which of the following are used by most insurers when determining the premiums for large groups? Large number rating. Group rating. Area rating. Experience rating.

Experience rating.

A comprehensive major medical health insurance policy contains an Eligible Expenses provision which identifies the types of health care services that are covered. All of the following health care services are typically covered EXCEPT for Hospital charges. Physician fees. Experimental and investigative services. Nursing services.

Experimental and investigative services.

Federally qualified HMO's must offer Dental coverage. Urgent care. Family planning services. Custodial care.

Family planning services.

Where does the primary funding for Medicare Part A come from? Private funding. Insurance company funding. State funding. Federal payroll and self-employment taxes.

Federal payroll and self-employment taxes.

Medicare Part A does NOT provide coverage for Inpatient room and board. Inpatient prescription medication. First 3 pints of blood. Skilled nursing facility care.

First 3 pints of blood.

Major Medical policies are typically characterized by which of the following? Corridor deductible. Flat deductible. Probationary period. First dollar coverage.

Flat deductible.

The "Use it or Lose it" rule applies to Medical Savings Accounts. Health Savings Accounts. Health Reimbursement Accounts. Flexible Savings Accounts.

Flexible Savings Accounts.

Which of these is NOT a factor during the health insurance underwriting process? Current residence. Physical condition. Occupation. Former residence.

Former residence.

Select the appropriate response A major medical expense plan typically includes coverage for hospital room and board. Which of the following is normally covered under the category "room and board"? Surgeon's fee. Diagnostic services. Prescription medication. General nursing care.

General nursing care.

When the disclosure of an insured's nonpublic information is involved, what is the insurer obligated to do? Insurer is not obligated to take any action. Insurer is obligated to verify that the agent is in compliance. Give notice, explain, and allow opting out. Provide the proper NAIC paperwork.

Give notice, explain, and allow opting out.

An insured may be required to sign which document at policy delivery to ensure there has not been any adverse medical conditions since the time of the application? Binding receipt. Good health statement. Agent's report. MIB disclosure.

Good health statement.

Which of the following health plans pay benefits on a pre-paid service basis? Medicare. Medicaid. Group medical expense. HMO.

HMO

An accident and health plan that typically covers ONLY the services of approved providers is called a(n) HMO plan. POS plan. PPO plan. Major medical plan.

HMO plan.

An organization that requires healthcare services to be provided by a network of physicians and hospitals is known as a(n) PPO. HMO. POS. HDHP.

HMO.

Kyle is an insured who disregarded an accident and health insurance policy provision that requires him to seek a second surgical opinion. What will the end result be? He may be reimbursed for the surgical procedure at a reduced benefit level. He may be reimbursed for the surgical procedure at a higher benefit level. He will have to start paying higher premiums starting with the next billing cycle. He will be ineligible to receive any benefits for this procedure.

He may be reimbursed for the surgical procedure at a reduced benefit level.

Tonya has been diagnosed with kidney failure and is covered by group accident and health insurance through her large employer. Which of these accident and health plans will be primary during the months immediately following her diagnosis? Medicare. Medicaid. Medicare Supplement. Her employer's group accident and health plan.

Her employer's group accident and health plan.

Lamont has a point-of-service plan and is seeking to obtain health services outside the network. What will likely be the end result? Reduction in care given. Higher out-of-pocket costs. Increase in premiums. Denial of specialized services.

Higher out-of-pocket costs.

What can be expected when a preferred provider organization (PPO) patient decides to use a non-PPO? Higher out-of-pocket expenses. Lower out-of-pocket expenses. 100% coverage. No coverage.

Higher out-of-pocket expenses.

A medical fee schedule shows the amount an insurer will pay for a given procedure. This amount is considered to be the Negotiated amount payable. Average amount payable. Lowest amount payable. Highest amount payable.

Highest amount payable.

Terry receives long-term physical therapy at her residence. What type of insurance would cover this service? Home health care. Long-term disability income. Nursing home. Respite care.

Home health care.

A family counseling benefit is typically offered under which of these coverages? Skilled nursing care. Respite care. Home health care. Hospice care.

Hospice care.

Some standard Medicare Supplement policies include which benefit? Hospice care. Respite care. Vision care. Custodial care.

Hospice care.

Which of the following is NOT true of a preferred provider plan? If service is obtained outside the preferred provider plan, benefits are reduced and costs increase. Members of the preferred provider plan select from among the preferred providers for needed services. Hospitals can only initiate preferred provider plans. Preferred provider plans can include dental care.

Hospitals can only initiate preferred provider plans.

A characteristic of preferred provider organizations (PPO) is PPOs operate like an HMO on a prepaid basis. If service is obtained outside the PPO, benefits are reduced and costs increase. PPOs are generally public in nature rather than private. Health care providers themselves are barred from forming a PPO due to conflict of interest.

If service is obtained outside the PPO, benefits are reduced and costs increase.

In a staff model HMO, enrollees normally have which of the following pharmacy options available to them? Mail-order pharmacy. In-house pharmacy. Captive pharmacy. Network pharmacies.

In-house pharmacy.

A health insurance underwriter will most likely view alcohol abuse as a(n) Decreased exposure to risk. Increased exposure to risk. Condition which cannot be taken into account. Condition which results in an automatic rejection for coverage.

Increased exposure to risk.

The type of health insurance in which underwriting procedures are the most restrictive is Accidental. Individual. Group. Employer-paid.

Individual.

Which of these procedures is NOT designed for ambulatory care centers? Inpatient surgery. Vaccinations. Outpatient surgery. Physical examinations.

Inpatient surgery.

The Medical Information Bureau consists of members from which group? Doctors. Hospitals. Insurance companies. Underwriters.

Insurance companies.

Who is protected with the "other insurance with this insurer" provision? Insurance company. Insured. Policyowner. Claimant.

Insurance company.

Who must sign a rider attached to a health insurance policy in order for it to be valid? Producer only. Insured only. Insured and producer. Insurance company underwriter.

Insured and producer.

Which of these statements reflects an accurate portrayal of Medicare SELECT? Insured uses preferred providers in exchange for paying lower premiums. Evidence of insurability must always be given before enrollment. Medicare SELECT is normally subject to deductibles and coinsurance. Open enrollment periods do not apply to Medicare SELECT plans.

Insured uses preferred providers in exchange for paying lower premiums.

Which health policy clause specifies the amount of benefits to be paid? Insuring. Consideration. Free-look. Payment mode.

Insuring.

Andy is in need of health care performed by skilled medical practitioners, but only on an intermittent basis. What level of care will his doctor likely prescribe? Respite care. Intermediate care. Custodial care. Skilled nursing care.

Intermediate care.

After a health insurance application has been originated, the producer normally Can change the policy provisions. Determines whether a claim will be paid. Is the major personal contact to the insured. Conducts a physical examination.

Is the major personal contact to the insured.

An applicant for accident and health insurance has a risk factor that is similar to a majority of the insurer's other applicants. What will be the likely outcome of this applicant? Issued with a below-standard premium rate. Issued with a standard premium rate. Issued with an above-standard premium rate. Declined coverage.

Issued with a standard premium rate.

Which of the following statements regarding hospital pre-admission authorization is NOT true? No delays for emergency treatment. It encourages weekend admission. Non-emergency situations require notification to the insurance company. Other types of treatment may be encouraged.

It encourages weekend admission.

Ken is age 65 and has 2 years until he receives Social Security retirement income benefits. At his current age, which is true about Medicare Part A Hospital Insurance coverage? It is available through application to Homeland Security. It is available through application to Social Security. He is automatically enrolled through his employer He is not eligible until he starts receiving social security retirement income.

It is available through application to Social Security.

The initial premium for an accident and health insurance policy is typically paid in what way? The applicant mails it to the insurer after the policy has been approved. It is typically obtained by the agent and forwarded to the insurer. It is typically forwarded to the insurer by the applicant. The agent pays it from any commissions received.

It is typically obtained by the agent and forwarded to the insurer.

After the initial enrollment period for Medicare Part B has expired, when may an individual purchase again? January through March of each year. October through December of each year. Six months after the individual's birthday month of each year. Three months after the individual's birthday month of each year.

January through March of each year.

All of these are duties that a producer may be required to perform when delivering an insurance policy EXCEPT Acquire a statement of good health signature. Gather the initial premium. Review policy with applicant. Leave a conditional receipt with client.

Leave a conditional receipt with client.

Health care costs can be better controlled by utilizing preadmission testing. Preadmission testing can reduce the Surgeon's fees. Prescription drug charges. Length of hospitalization. Elimination period.

Length of hospitalization.

Inpatient psychiatric care is covered under Part A Medicare for 190 days per Admission. Year. Benefit period. Lifetime.

Lifetime.

What is covered under a limited accident and health insurance policy? Losses that occur only in limited occupations. Limited pre-existing conditions. Losses that occur only in limited age groups. Limited perils and amounts.

Limited perils and amounts.

An insurance policy may be issued with a preferred insurance premium in all of these situations EXCEPT Good credit history. Living in a rural area. Good health history. Being a nonsmoker.

Living in a rural area.

Respite Care coverage is typically found in a(n) HMO. PPO. Long Term Care policy. Major Medical Expense policy.

Long Term Care policy.

Custodial care is normally covered under Major medical insurance. Medicare Part B. Long-term disability insurance. Long-term care insurance.

Long-term care insurance.

Employees generally receive workers compensation benefits for Only medical expenses due to occupational accidents. Employment termination. Lost wages and medical expenses due to occupational accidents. Only lost wages due to accidents that occur on the job

Lost wages and medical expenses due to occupational accidents.

Which of these policies is considered to be a comprehensive health policy? Major medical policy. Surgical policy. Limited benefit policy. Health Savings Account.

Major medical policy.

A MET third-party administrator may NOT perform which of the following functions? Claims processing. Marketing the plan. Underwriting the plan. Insuring the plan.

Marketing the plan.

Karen is considering replacing her individual accident and health insurance policy with another individual policy. She has had issues in the past with her gall bladder that would be considered a pre-existing condition. How will a pre-existing conditions exclusion affect Karen's new insurance contract? Will not affect the new contract at all. May increase her benefits. May reduce her benefits. Will permanently exclude her from insurance coverage.

May reduce her benefits.

Field underwriting by a producer Is used to reduce costs to the insurer. Involves conducting a physical examination of the applicant. May result in the disclosure of hazardous activities of the applicant. Is illegal in most states.

May result in the disclosure of hazardous activities of the applicant.

Medicare Part A coinsurance payments are covered by Part B Medicare. Part D Medicare. Medicare Supplement Plan A. Never covered.

Medicare Supplement Plan A.

Which of these is a type of private insurance that covers the cost-sharing amounts under Medicare? Major medical insurance. Medicaid. Disability income. Medicare Supplement.

Medicare Supplement.

Medicare Part B excess charges are covered by long-term care policies. respite care. Medicare Part A. Medicare Supplemental insurance.

Medicare Supplemental insurance.

Which individual would be best suited for Medicare Supplement insurance? Medicare enrollee. Medicaid enrollee. Social Security recipient. HMO subscriber.

Medicare enrollee.

Skilled nursing facility expenses are sometimes covered by _____, but ONLY if the insured was hospitalized prior to entering the facility. HMOs. Medicare. Medicaid. Medicare Supplements.

Medicare.

Which of the following does TRI-CARE provide accident and health coverage to? Military families. Social Security recipients. Permanently disabled individuals. Children.

Military families.

Which statement is true regarding hospital preadmission certification for emergency situations? Notification is not required for emergency situations. Insured cannot be admitted without preadmission certification. Notification is required to be given before insured is admitted to the hospital. Notification is required to be given after insured is admitted to the hospital.

Notification is required to be given after insured is admitted to the hospital.

An insured is covered with a health insurance policy. If the insured would like to cancel the policy, he/she must Wait until the end of the calendar year. Notify the insurance company in writing. Notify the insurance company by telephone. Provide a reason for cancelling.

Notify the insurance company in writing.

Long-term care policies normally cover expenses associated with Drug and alcohol dependency treatment. Halfway homes. Nursing homes. Intensive care units.

Nursing homes.

Which statement is NOT true regarding health insurance policies that provide limited benefits? Only persons under the age of 65 are eligible. Coverage may be limited to a specific dread disease, such as cancer. Benefits may be paid on a reimbursement or indemnity basis. Benefits may be paid on a reimbursement or indemnity basis.

Only persons under the age of 65 are eligible.

Julie is an employee with a group health plan that contains the Mandatory Second Surgical Opinion provision. What is to be expected with this provision in place? Mandatory second surgical opinions are required when emergency surgery is needed. The second surgical opinion must always be accepted by the insured. Out-of-pocket expenses are higher when a second surgical opinion is obtained as opposed to having only one. Out-of-pocket expenses are lower when a second surgical opinion is obtained as opposed to having only one.

Out-of-pocket expenses are lower when a second surgical opinion is obtained as opposed to having only one.

Which of the following is NOT true of participants in multiple-employer trusts? Participants are normally small employers. Participants must purchase all coverages the trust offers. Participants are typically all in the same industry group. Joinder agreement is issued to participants.

Participants must purchase all coverages the trust offers.

A physician who accepts assignment on all Medicare claims is called a(n) Participating provider. Authorized provider. Registered provider. Admitted provider.

Participating provider.

When a health insurance policy includes a Mandatory Second Surgical Opinion provision, the insured must Cover the cost of the second opinion. Seek a second opinion for all surgeries. Seek a second opinion for specified elective surgeries. Seek a second opinion for emergency surgery.

Seek a second opinion for specified elective surgeries.

Which of these is NOT considered the responsibility of a producer in the underwriting process? Collecting additional medical information if needed. Promptly sending the completed application to the insurance company. Forwarding any material personal observations to the insurer. Selecting the final approval date.

Selecting the final approval date.

Third-party administration has become fairly common in accident and health insurance due to the growth of The Affordable Care Act. Self-funding of benefits. Health savings accounts. Medicaid.

Self-funding of benefits.

Medicare Part A covers which type of care? Skilled nursing facility care. Custodial care. Respite care. Intermediate nursing facility care.

Skilled nursing facility care.

Which of the following does a Medicare Advantage enrollee typically pay for? Retainer fee. Annual deductibles. Small co-pay per visit or per service. Capitation.

Small co-pay per visit or per service.

An individual may receive Medicare Part A Hospital benefits, regardless of age, as long as the person has received which of the following benefits for at least 24 months? Unemployment. Workers compensation. Medicaid. Social Security Disability.

Social Security Disability.

Kelly purchases a health insurance policy issued on a conditionally renewable basis. The insurance company has a right to refuse renewal of the policy for Any change in Kelly's health. Specific reasons stated in the contract. Any reason the insurer sees fit. Profitability reasons.

Specific reasons stated in the contract.

Individuals who participate in an HMO plan are called Certificate holders. Subscribers. Policyowners. Beneficiaries.

Subscribers.

Qualified long-term care premiums are treated for tax purposes as Qualified Retirement plans. Always non-deductible. 100% tax-deductible. Tax-deductible to the extent they exceed 7 1/2% AGI.

Tax-deductible to the extent they exceed 7 1/2% AGI.

Which of the following is a true statement regarding a Medicare Supplement policy purchased during the open enrollment period? There will be a reduction in benefits. The elimination period will be longer than normal. The cost of premiums will be higher than normal. The policy will be issued regardless of health.

The policy will be issued regardless of health.

In accident and health insurance, field underwriting is very important because of The protection given to the producer's commission. The opportunity to charge a higher premium. Inflation. The risk of a moral hazard.

The risk of a moral hazard.

How is a community rating used for underwriting purposes? Each member of a large group is individually underwritten. Each individual and group plan in the same geographical area is individually underwritten. The same rates are charged for individual and group plans in the same risk category. The same rates are charged for individual and group plans in the same geographical area.

The same rates are charged for individual and group plans in the same geographical area.

How is an insured's accident and health claim handled by an insurer if it occurs during the policy's grace period? The claim has to be approved by an officer of the insurer. No claim will be paid until premium is paid current. The claim is paid in full and the unpaid premium will be waived by the insurer. The unpaid premium may be subtracted from the reimbursement.

The unpaid premium may be subtracted from the reimbursement.

The major medical deductible carryover period normally applies to expenses incurred during the last ___ months of the plan year. Five. Four. Three. Two.

Three.

Which of the following does medical expense insurance NOT typically cover? X-rays. Treatment in a government facility. Hospitalization. Diagnostic testing.

Treatment in a government facility.

The grouping of two or more small employers in order to obtain group health insurance at a favorable rate is called a multiple employer Grouping. Trust. Alliance. Corporation.

Trust.

How does an underwriter take into account an applicant's marital status? When determining if a policy will be issued. When determining if an applicant is insurable. When determining who is eligible for dependent coverage. When determining if a rating will be placed on a policy.

When determining who is eligible for dependent coverage.

Under what circumstance does an accident and health insurer have the right to request an autopsy? When the claim exceeds an amount specified in the policy. When 2 days have passed after death. When not prohibited by state law. When consent is given by the beneficiary.

When not prohibited by state law.

A producer gives a conditional receipt to a client for an insurance policy after collecting the initial premium. When will the policy become effective? When the policy is issued. The date of policy delivery. When the conditions of the receipt are met. The date the sales appointment was set.

When the conditions of the receipt are met.

When does the producer give a premium receipt for an accident and health insurance application? When the application has been approved. When the initial premium has been collected with the application. During the medical exam. When the completed application has been collected.

When the initial premium has been collected with the application.

A health insurer MUST provide a proof of loss form Within 10 days of the actual loss. Within 10 days of receipt of the notice of loss. Within 15 days of receipt of the notice of loss. Within 15 days of the actual loss.

Within 15 days of receipt of the notice of loss.

Medicare supplement insurance that provides a preventative medical care benefit will often cover Respite care. Hospitalization. Custodial care. Yearly physical examinations.

Yearly physical examinations.

Medicare Part A typically covers inpatient drugs. custodial care. disability income. respite care.

inpatient drugs.

Inpatient psychiatric care is covered under Part A Medicare Insurance for 190 days per billing period. hospital visit. year. lifetime.

lifetime.

A signed good health statement may be collected by a producer at the time of policy issue. application. policy delivery. physical examination.

policy delivery.

After joining a health maintenance organization (HMO), a subscriber will typically select a capitation level. primary care physician. closed panel. deductible level.

primary care physician.