Exam Time Baby!

Elane's Basic Hospital Expense policy has a 500 per day limit for room and board in a hospital for a max of 5 days. Elaine got sick and had to spend 3 days in the hospital at 650 a day. How much will Elaine have to pay to cover the rest of her room and board charges?

- 0 - 150 - 350 - 450

Which of the following statements is NOT true regarding health insurance policy provisions

- All individual policies contain Uniform mandatory Provision - Insurers may only offer optional provisions that are allowed by the state where the policy is delivered - Insurers may add provisions that are not in conflict with uniform standards - all additional provisions written by insurers are cataloged by their respected states

In addition to participation requirements, how does an insurer guard against adverse selection when underwriting group health?

- By requiring that the insurance be incidental to the group - by having each enrollee undergo a paramedical examination - by obtaining MIB reports on each enrollee - by imposing case management provisions

Features of Guaranteed renewable provision?

- The insured has a unilateral right to renew the policy for the life of the contract - coverage is not renewable beyond the insured's age 65 - the insured's benefits cannot be reduced

An elimination period may not have to be satisfied for a disability in which of the following

- an insured suffers a relapse of a prior disability within 6 moths of the intial covered disability - an insured suffered the diability from the results of active duty an insured is disabled from a work-related accident - as insured contracted an incurable disease

What is covered under Plan A in Medigap Insurance

- approved hospital costs for 365 additional days after Medicare benefits - The 20% Part B coinsurance amounts for Medicare approved services - The first three pints of blood each year

To be valid, an insurance policy must have all of the following EXCEPT

- countersignature -acceptance -consideration -offer

In order for an alumni association to be eligible to purchase group health insurance for its members, all of these statements must be true EXCEPT when the association..

- has been active for 5 years - has a constitution by laws and must hold annual meetings - is organized for reasons other than buying insurance - has at least 100 members

Medicaid provides what?

- home health care services - eyeglasses - family planning services

Medicaid correct statements

- individuals claiming must prove they do not have the ability or means to pay for their own medical care - personas, at least 65 years of age, who are blind or disabled and financially unable to pay, may qualify for Medicaid Nursing Home Benefits - Individual states design and administer the Medicaid program under broad guidelines established by the federal gov.

Correct statements about Medicaid

- it provides medical assistance to low income people - it pays for hospital care, outpatient care, labs, and x ray - the federal government provides 56 cents for every Medicaid dollar spent

Medicare Part A services include

- post hospital skilled nursing facility care - hospice care - hospitalization

Medicare SELECT policy does what?

- provide payment for full coverage under the policy for covered services not available through network providers - provide for continuation of coverage in the event that Medicare SELECT policies are discontinued due to failure of the Medicare SELECT program. - Make full and fair disclosure in writing of the provisions, restrictions, and limitations of the medicare SELECT policy to each applicant

An insured purchased a health insurance policy with a renewability clause that states the policy is "guaranteed renewable". This means that as long as the required premiums are paid, the policy will continue until the insured

- reaches age 65

What are exclusions in medical expense insurance policies

- self inflicted injuries - military duty - routine dental care

Features of a noncancellable policy

- the guarantee to renew coverage usually applies until the insured reaches certain age - the insured has the right to renew the policy for the life of the contract - the premiums cannot be increased beyond the amount stated in the policy

What is true about the right of Renewability for cancellable polices?

- the insurer must provide the insured a written notice of the cancellation - claims incurred before cancellation must be honored - an insurance company may cancel the policy at any time

As part of the policy approval process, the commissioner may require the insurer to provide all of the following EXCEPT?

- the producers commission schedule - advertising material use with the policy - the premium rates filed with the policy - a copy of the policy

Which of the following services will NOT be provided by an HMO

- unlimited coverage for treatment for drug rehabilitation - treatment of mental disorders - emergency care - inpatient hospital care outside the service area

What are allowable reasons for an insurer to cancel a noncancellable health insurance policy?

- within 2 years of application, the insurer discovers a misrepresentation - the insured does not pay premium - the insured reaches the max age limit in the policy

What are factors for determining Social Security Disability benefits?

1. Workers PIA 2. Workers Age 3. Number of work credits earned

What does the Insuring Clause specify?

1. the insurance company 2. the name of the insured 3. covered perils

An insured pays a monthly premium of $100 for her health insurance. What would be the duration of the grace period under her policy?

10 days

If a producers license lapses, how much time does the producer have to apply for reinstatement without having to take an exam?

12 months

Proof of loss forms must be sent to the insured within____ days of notice of claim

15

To appoint a producer, the commissioner must know within how many days

15 days

If a license lapses, the commissioner suspends you license for how long?

2 years after the license was last effective.

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

For each licensing period, licensees must complete how many hours of continuing education?

24 hours

The relation of earning to insurance provision allows the insurance company to limit the insured's benefits to his/her average income over the last:

24 months

Ab insurer must notify the consumer in writing that an investigative consumer report has been requested within how many days of the initial request?

3 5 10 30

The commissioner must verify that the insurance producer is eligible within how many days

30 days

Under Social Security disability benefits, a person will have to wait how many months before any benefits will be paid?

5 months

What coinsurance agreement would result in the lowest premium possible?

50/50

How long is an open enrollment period for Medicare supplement policies

6 months

Randy loses his full time job because his role in the company becomes obsolete. How long must he be given the option of continuing his group health insurance coverage, provided he doesn't find coverage somewhere else?

6 months 12 months 18 months 24 months

Under the mandatory uniform provision Legal Actions, an insured is prevented from bringing a suit against the insurer to recover on a health policy prior to:

60 days after written proof of loss has been submitted

Under the uniform required provisions, proof of loss should be filed when?

90 days

Under the uniform required provisions, proof of loss under a health insurance policy normally should be filed within

90 days

Medicaid

A health care payment program sponsored by federal & state governments. It expands individual public assistance programs for people with insufficient income and resources

A free look provision allows for which of the following

A right to return the policy for a full refund

Under the mandatory uniform provision Notice of Claim, the first notice of injury or sickness covered under an accident and health policy must contain

A statement that is sufficient clear to identify the insured and the nature of the claim.

What is the max period of time during which an insurer may contest fraudulent misstatements made in a health insurance application?

As long as the policy is in force

According to the metal level what percentage will be covered under the plans?

Bronze: 60 Silver: 70 Gold: 80 Platinum: 90

Waiver of Premium rider?

Causes the insurer to waive future premium when an accident or disease causes a disability lasting at least 6 months

The provision that provides for the sharing of expenses between the insured and the insurance company is?

Coinsurance

An applicant for individual health policy failed to complete the application properly. Before being able to complete the application and pay the initial premium she is confined to a hospital. This will not be covered because she has not met the conditions specified in what clause?

Consideration Clause

A reinstated policy provides immediate coverage for what?

Covers accidental injury. Sickness is covered only if the sickness occurs at least 10 days after the reinstatement date

The provision that states that both the printed contract and a copy of the application form the contract between the policyowner and the insuerer is called the?

Entire Contract

The provision in a health insurance policy that ensures that the insurer cannot refer to any doc that is not contained in the contract is the___

Entire Contract clause

A medicare supplement plan must have at least which of the following renewal provisions?

Guaranteed renewable

What is covered by Medicare?

Hospital, hospice, Respite

Carry over provision

If the insured did not incur sufficient medical costs during the year to meet the deductible, any medical expense incurred during the last three months may be carried forward to next year, offsetting the total deductible costs for that year

Which of the following riders would NOT increase the premium for a policyowner

Impairment rider

The section of a health policy that states the causes of eligible loss under which an insured assumed to be disabled is the

Insuring Clause

Which of the following policy provisions is a general statement identifying the insured, the instance company, and the types of loss that will be covered

Insuring Clause

In health insurance, if a doctor charges 50 dollars more than what the insurance company considers usual customary and reason, the extra cost will do what?

It will not be covered

In a group health policy, a probationary period is intended for people who:

Join the group after the effective date

The provision which prevents the insured from bringing any legal action against the company for at least 60 days after proof ofl oss is known as:

Legal Actions

Which of the following whole life policies charges a level annual premium for the lifetime of the insured

Level Term

Under an individual policy, the MINIMUM schedule of time in which claim payments be made to an insured is:

Monthly

The primary eligibility requirement for Medicaid benefits is based upon

Need

What provision concerns the insureds duty to provide the insurer with reasonable notice in the event of a loss?

Notice of Claim

Medicare Advantage is also known as

Part C

What provision would prevent an insurance company from paying a reimbursement claim to someone other than the policyowner?

Payment of Claims

What must be present in all medicare supplement plans

Plan A

Insurers may change what on a guaranteed renewable health insurance policy?

Rates by class

The commissioner may verify a nonresident applicant's license status through who?

The NAICs producer database

What is the deductible of a personal liability umbrella policy called?

The SIR

Coinsurance and premiums

The larger the percentage that is paid by the insured, the lower the required premium will be

Which of the following varies the length of the grace period?

The mode of premium payment

A policy with a 31-day grace period implies

The policy will not lapse for 31 days if the premium is not paid when due

Irrevocable Beneficiary

They can be changed only with the written consent of that beneficiary

An insured notifies the insurance company that he has become disabled. What provision states that claims must be paid immediately upon written proof of loss?

Time of Payment of Claims

Which provision states that the insurance company must pay medical expense claims immediatley?

Time of Payment of Claims

According to the rights of renewability rider for cancellable policies, all of the following are correct about the cancellation of an individual insurance policy EXCEPT

Unearned premiums are retained by the insurance company

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

An insured owes his insurer a premium payment. Since then , he incurs medical expenses. The insurer deducts the unpaid premium amount from the claim amount and pays the insured the difference. What provisions allows for this?

Unpaid Premium

Manny has been injured in an accident. Although she is still receiving benefits from her policy, she does not have to pay premiums. Her policy includes

Waiver of Premium rider

Stop-loss limit

a specified dollar amount beyond which the insured no longer participates in the sharing of expenses

Renewability Rider allows what?

allows the insurer to cancel the policy at any time, or at the end of the policy period. Any unearned premiums must be returned to the policyholder. If the insurer cancels, the unearned premium will returned on a pro rate basis

In property policy, which of the following policy provisions states that the interest in a policy may be transferred?

assignment

Impairment Rider

excludes a specified condition from coverage, therefore, reducing benefits. An insurance company will not charge extra for a rider that reduces benefits.

Once a person becomes eligible for Medicare Supplement Plans and during the open enrollment period, coverage must be offered on a ____ basis.

guaranteed issue basis

When reinstatement occurs, when does coverage start?

immediately for accidents, sickness has a waiting period for 10 days.

Long term care producers have to complete what?

initial 8 hour training course, and on going 4 hour training every 24 months

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

A guaranteed renewable disability insurance policy

is renewable at the insureds option to a specified age

If this occurs, the applicant can do what?

make a written demand within 30 days for a hearing to determine why.

In the event that the action by the commissioner is to non renew or deny an application, the commissioner must do what

must notify the applicant or licensee and advice in writing

In respect to the consideration clause, which is consideration on the part of the insurer

paying for the loss

Part B of Medicare

pays 80% of out-patient medical cost after a deductible has been met. Part B covers physician and outpatient hospital services, and other medical and health services such as diagnostic test and physical therapy.

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.

Which of the following is NOT mandatory under the Uniform Provisions Laws applied to accident and health policies

probationary period

Insurers are forbidden to do all of the following with their advertisements, EXECPT

promote interest in insurance coverage

What is the purpose of the impairment rider in a health insurance policy?

to exclude coverage for a specific impairment

The insuring clause of disability policy usually states all of the following

types of losses covered, identities of the insurance company and the insured, that insured against loss is provided.