CH.8

Samuel Johnson pays his health insurance premium quarterly. If he fails to make payment on April 1, when will his grace period expire?

1-May

How long is the grace period for individual health insurance coverage paid on a monthly basis?

10 days

Select one:

10 days

Upon receipt of a notice of claim, the insurer must provide the potential claimant the proper claims form within how many days?

15 days

For individual health insurance policies, legal action may be taken against the insurer for up to ____ years from the date proof of loss is provided to the insurer.

3

Adam fails to pay his premium for his health insurance policy before the end of the grace period. A couple months later, Adam decides he wants to reinstate his policy. He submits a policy application to the insurance company. Adam does not receive a reply from the insurer. If his application is accepted, when will the policy be reinstated?

45 days after the reinstatement application is submitted to the insurer

For how many days must an insured wait after filing a claim with an insurance company before filing a legal suit against the company?

60 days

For individual health insurance policies, how soon must the insured submit proof of loss to the insurer?

90 days

What type of health plan is offered by BlueCross BlueShield?

All of the above

Why is disability insurable with health insurance?

Because disability may prevent a person from earning an income.

What type of group health plan is best suited for McKinley High's soccer team?

Blanket

Which of the following health plans is nonprofit, provides medical care on a service basis and is sometimes referred to as a producer cooperative?

BlueCross BlueShield

Which of the following is a prepaid health care organization?

BlueCross BlueShield

Which plan is nonprofit, provides medical services to subscribers on a service basis and is called a producer cooperative"?

BlueCross BlueShield

Carla has a limited health policy. She does not have a/an:

Cafeteria plan

Which of the following plans allows employees to receive health care catered to their unique needs?

Cafeteria plan

Producers must be careful when an insured wants to replace existing health insurance coverage. Considerations do not include:

Claims procedures

Medical expense insurance may cover all of the following, EXCEPT:

Disability income

Select one:

Disability income

Which health insurance policy pays periodic benefits to an insured?

Disability income

Annie has a policy that pays her a monthly income while she is disabled and cannot work. What policy does Annie have?

Disability income policy

All of the following are true regarding franchise health insurance, EXCEPT:

Each individual pays a separate premium.

Of the following health insurance provisions, which states that an insurance agent may not waive any provision or make any change in an insurance contract?

Entire contract

John has a medical plan in which medical providers are paid a dollar amount based on the services they provide to him. This is what type of plan?

Fee-for-service

Which of the following terms describes a medical plan that pays medical providers a dollar amount based on the services provided?

Fee-for-service

Which of the following terms describes a payment method in which medical providers are paid for each medical service they provide?

Fee-for-service

Which payment method is used to pay medical providers for each service they provide, and only for the medical services insureds use?

Fee-for-service basis

What type of health insurance is not technically group insurance, covers a small group of people for less than traditional group insurance, and each individual covered is issued an individual policy?

Franchise

Coverage for groups not large enough to apply for group coverage can be provided by:

Franchise insurance

This type of health coverage is available to smaller groups who are not large enough to qualify for group health plans:

Franchise insurance

Which type of health insurance policy is created for use by smaller groups who do not have enough eligible employees to qualify for a group health plan?

Franchise insurance

All of the following are provisions that relate to the filing of claims and payment of benefits in health insurance, EXCEPT:

Grace period

_______ health insurance is typically more affordable than ________ insurance.

Group; individual

All of the following are specific types of government health insurance programs, EXCEPT:

HMO

If a company decides to reinstate a policy, when does coverage begin for losses caused by accident?

Immediately

Select one:

Individual health insurance policies

Health insurance can be written:

Individually or on a group basis

All of the following are underwriting considerations for replacing health insurance coverage, EXCEPT:

It is the applicant's responsibility to assure the replacing coverage is for the insured's best interest.

Which of the following is not true about Medicare?

It provides coverage for people with limited incomes.

What happens to Jacob's policy if he does not pay the premium by the end of the grace period?

Jacob's policy will lapse.

All of the following are government health insurance programs EXCEPT:

Long-term care

The principal losses related to accident and health insurance are:

Loss of income from disability and medical expenses from the cost of medical treatments, physician's fees, hospitalization and prescriptions

Chuck buys a health insurance policy that covers the cost of physician outpatient office visits. Which of the following health policies best describes Chuck's policy?

Medical expense

Which statement is false regarding medical expense policies?

Medical expense policies pay for loss of income.

Frank has a policy that pays for his outpatient physician's fees and treatment when he injures his arm. What policy does Frank have?

Medical expense policy

All of the following are required provisions under the NAIC Uniform Provisions Law, EXCEPT:

Misstatement of age

How may medical expense plans pay benefits?

On a fee-for-service basis

What policy document discloses important details about the policy such as the names of the insurance company and agent, type of policy, and any attached riders?

Outline of coverage

Commercial insurers:

Pay health insurance benefits on a reimbursement basis

While investigating a current claim, an insurance company learns the insured claimant had not included their full medical history on the application and that the current claim results from a condition that was probably pre-existing 4 years ago, when the application was approved. The company will:

Pay the claim

A reimbursement contract will contain which of the following features:

Payment for hospital and surgical expenses incurred.

The facility of payment clause is typically a part of which provision?

Payment of Claims provision

Which of the following is not true regarding medical expense policies?

Pays loss of income benefits

Bob has a disability income policy that ________________.

Pays periodic income benefits when an insured cannot work due to a disability.

The entire contract provision in a health and accident policy includes certain basic parts. These are:

Policy and endorsements and application

All of the following are false regarding pre-existing conditions, EXCEPT:

Pre-existing conditions are excluded for a specified period stated in the policy, after which period they may be covered.

Which of the following is not a true characteristic of health insurance?

Premiums can be paid annually, monthly, weekly or daily.

Who is responsible for giving the applicant the outline of coverage for a health insurance policy?

Producer

Which of the following is not a responsibility of the insurer in individual health insurance?

Providing the applicant the Outline of coverage

An insurer may require all of the following to reinstate a health policy, EXCEPT:

Reinstatement application fee

What type of employer-administered health plan provides funding for claims payments for its employees and dependents?

Self-funded

All of the following are commercial health insurers, EXCEPT:

Service providers

Which of the following is not true about Social Security disability benefits?

Social Security pays partial and short term disability benefits.

The facility of payment clause:

States benefits are payable to an individual who is related to the deceased insured by blood or marriage

An insured requests a claim form from their insurer for a covered loss. The health insurer fails to send out claims forms to the insured within the time period required by the claims form provision. Under the claims form provision, the insured should:

Submit the claim using any form, which the insurer is obliged to accept as proof of loss

What is the term insurers use for individuals who receive health insurance on a prepaid health plan?

Subscriber

Individuals insured under a BlueCross BlueShield plan are called:

Subscribers

An employer that has a self-funded health plan, but contracts out claims processing, has hired a(n):

TPA

For individual health insurance policies, who is responsible for paying the cost of autopsy or examination of an insured, according to the physical examination and autopsy provision?

The insurance company

Under the claim forms provision, what is the insured allowed to do, if the insurer does not provide claim forms within 15 days?

The insured may submit the written proof of loss on any form or manner to the insurer.

According to the Physical Examination and Autopsy provision, who is responsible for paying the cost of examining the insured?

The insurer

Which of the following best describes the claims forms provision?

The insurer must supply claim forms to the insured within 15 days.

Health insurance covers:

The risk of loss caused by a living death

How much time does an insured have after filing a claim with an insurance company in which to file a legal suit against the insurer?

Three years from the date proof of loss is furnished

"Indemnities payable under this policy for any loss will be paid immediately upon receipt of due written proof of loss." This statement appears in the:

Time of payment of claims provision

All of the following are type of benefits that are offered under health insurance, EXCEPT:

Traditional IRAs

Health insurance benefits paid based on the average charges in a particular geographic area for each procedure or treatment are termed:

Usual, reasonable and customary

All of the following are ways medical expense plans may pay benefits, EXCEPT:

Valued basis

For individual health insurance policies, how soon must the insured/claimant provide the insurance company with notice of claim?

Within 20 days of the date of loss

For individual health insurance policies, how soon must the insured/claimant submit proof of loss to the insurance company?

Within 90 days of the date of loss

By law, most states require employers to have this coverage:

Workers' Compensation

Which of the following is not an employer administered health plan?

Workers' Compensation

_____________ is health coverage that employers are required by law to have in most states.

Workers' Compensation

An employer-sponsored wellness plan that fosters healthier lifestyles for employees is a:

Worksite plan

Disability benefits are:

All of the above

Health insurance is intended to cover the risk of income loss caused by:

All of the above

Medical plan concepts include which of the following options?

All of the above

Adam's Paint Company provides all funds for its group health insurance plan, but uses an insurance company for the processing of claims. Which plan does Adam's Paint Company use?

ASO

What type of employer-administered health plan is self-funded, but an insurer handles all claims processing?

ASO contract

Limited insurance policies do not include:

Accident and sickness

What are the two perils addressed by health insurance?

Accidental injury and sickness

All of the following are false regarding the reinstatement provision for individual health policies, EXCEPT:

Accidents are covered immediately upon reinstatement, and sicknesses are covered after a 10-day waiting period.

TRICARE provides health insurance coverage for:

Active duty and retired military

Jerry's dry cleaning company provides all funds for its group health insurance plan, but uses an insurance company to process its claims. Jerry's dry cleaning company uses a/an:

Administrative services only contract