Health Insurance Exam Kentucky

C. Staff Model

A Health maintenance organization (HMO) in a certain city contracts with an independent medical group to provide services to HMO subscribers. The paying the individual medical practitioners, What type of HMO structure is this? A. Group Model B. Network Model C. Staff Model D. IPA Model

A. guaranteed renewable policy

A certain health insurance policy states that the insurer will not refuse to renew the policy and furthermore, the insurer may not cancel the policy. However, the insurer may change the premium by classes of insureds. This policy is A. guaranteed renewable policy B. an optionally renewable policy C. a conditionally renewable policy D. a noncancellable policy

B. inside limits

A certain major medical policy states a maximum number of X-rays that will be paid for under any one claim. These are examples of A. first dollar coverage B. inside limits C. carryover provisions D. stop-loss limits

D. Authorized Company

A company that I licensed to sell insurance in a particular state is A. domestic B. Alien C. non admitted company D. Authorized comany

C. presumptive disability

A disability that is presumed to result from the same or related cause of prior disability is called a A. recurrent disability B. residual disability C. presumptive disability D. delayed disability

A. Guaranteed Insurability

A health insurance policy includes an endormsemtn indicating the insurer will allow the policy to continue in force without further premiums if the insured is totally and permanently disabled. What endorsement is attached to this policy? A. Guaranteed insurability B. Impairment C. Multiple Indemnity D. Waiver of premium

A. A conditionally renewable policy

A health insurance policy that the insurer may choose not to renew only on the premium due date is called A. A conditionally renewable policy B. An optionally renewable policy C. A cancellable policy D. A guaranteed renewable policy

D. Neither A or B

A medicare SELECT policy differs from a regular Medigap policy in that it A. provides more coverages B. costs more C. Both A and B D. Neither A or B

C. a legal entity that makes group insurance available to small employers

A third party administrator is : A. an outside consultant that evaluates the quality of group health and welfare benefits B. an outside organization that manages employers self-insured plans C. a legal entity that makes group insurance available to small employers D. an arbitrator who works to settle health insurance claims

When proof of loss has been furnished, periodic benefit payments must be made not less frequently than A. Weekly B/ Monthly C. Semi-Annually D. Annual

A. Weekly B/ Monthly C. Semi-Annually D. Annual B. Monthly

B. 30 days and not longer than three years from the date of proof of loss

According to Required Provision 11, the insured is prevented fro filing suit against the insurer for at least A. 20 days and not longer than one year from the date of proof loss B. 30 days and not longer than three years from the date of proof of loss C. 60 days and not longer than three years from the date of proof of loss D. 90 days and not longer than five years from the date of proof of loss

C. pro rata basis, which means all unearned premium is returned to the signed

According to optional Provision 8, if the insurance company cancels a policy, on what basis must prepaid premiums be returned to the insured? A. short rate basis, which means all unearned premium is returned to the insured B. short rate basis, which means the insurer may retain part of the unearned premium in order to cover its expenses C. pro rata basis, which means all unearned premium is returned to the singed D. pro rata basis, which means the singer may retain part of the unearned premium in order to cover its expenses

D. all of the above

All medicare supplement (or Medigap) policies must A. have the same premium B. have the same core benefits C. duplicate benefits provided by Medicare D. all of the above

C. charge a higher than standard premium

All of the following are alternatives an insurer has when asked to insure a substandard risk EXCEPT A. reject the risk B. attach a rider to the policy excluding certain coverages or conditions C. charge a higher than a standard premium D. issue the policy with a probationary period after which the insurer may continue or cancel the policy

A. the application becomes part of the policy when attached to the policy

All of the following are reasons an application is important EXCEPT A. the application becomes part of the policy when attached to the policy B. the applications helps to fully identify the applicant C. statements made in the application become the basis for issuing the policy D. the application becomes part of the insuring clause when attached to the policy

C. The insurer may increase the premium rate after the policy is in effect provided it does so by classes of insureds

All of the following statements about non-cancellable policies are true EXCEPT A. A noncancellible police is also called a noncancellible and guaranteed renewable policy B. The only right to cancel the noncancellable policy is for nonpayment of premiums C. The insurer may increase the premium rate after the policy is in effect provided it does so by classes of insureds D. the insurer may regain the right to cancel or not to renew when they insured reaches and age specified in the policy

B. Conditional Receipt

An application for insurance may pay the initial premiums and recieve a document from the agent indicating that if the policy is issued as requested, coverage begins on the date of the document. What is this document called? A. Executing agreements B. Conditional receipt C. Warranty D. Notice of Inspection

A. "own occupation" definition and is more restrictive than other definitions

An insured disability income policy defines total disability as "the insureds inability to preform the duties of any occupation for which he or she is reaosnily qualified by education, training, or experience." This definition is known as the A. "own occupation" definition and is more restrictive than other definitions B. "any occupation" definition and is more restrictive than other definitions C. "own occupation" definition and is less restrictive than other definitions D. "any occupation" definition and is less restrictive than other definitions

C. is less restrictive than the phrase "accidental means"

An insured's accident policy uses the phrase "accidental bodily injury" to define what constitutes accidental injury and or resulting death. The phrase A. means the insured will recieve a lower benefit than a policy that uses the phrase accidental means B. means the same as the phrase "accidental means" C. is less restrictive than the phrase "accidental means" D. is more restrictive than the phrase "accidental means"

C. Less costly and have more liberal provisions

As compared to individual disability income policies, group disability income policies are generally A. More costly and have less liberal provisions B. More restrictive in terms of covered medical expense C. less costly and have more liberal provisions D. Tied more closely to Social Security disability benefits

An insured has an A + H policy with the phrase "Accidental Bodily Injury" used to define what constituted accidental injury or death A. This phrase is more restrictive than the phrase "Accidental Means" B. This phrase is less restrictive than the phrase "Accidental Means" C. This phrase means the same as "Accidental Means" D. This phrase means that the insured will receive fewer benefits than a policy using the phrase "Accidental Means"

B. This phrase is less retrieve than the phrase "Accidental Means"

C. Partially Disabled

Before Cranston was disabled, he was a full-time engineer earning about 70,000 annually. Now, two years later he is able to work part-time. earning about 25,000 annually. It is likely that Cranston would be classified as A. totally and permanently disabled B. recurrently disabled C. partially disabled D. not disabled at all

A. An irrevocable beneficiary

Brenda Names her husband as the beneficiary of the accidental death benefit in her health policy. She has relinquished her right to change the beneficiary designation. According to Required Provision 12, Brenda's husband is A. An irrevocable beneficiary B. Revocable Beneficiary C. Contingent Beneficiary D. A tertiary beneficiary

If an A + H policy provides any periodic payments contingent on continuing loss, written proof of loss must be furnished by the insured within how many days of termination of the period for which the insurer is liable? A. 30 days B. 60 days C. 90 days D. 180 days

C. 90 days

B. Limited Policies

Dread disease, travel accident, vision care, and hospital indemnity policies are all examples of A. ltc policies B. limited policies C. group policies D. blanket policies

D. name of the insured

Each of the following would be found in the insuring clause of an insurance policy EXCEPT A. General scoot of the coverage B. Conditions under which benefits are payable C. definitions D. name of the insured

A. tax-deductible to the employer

Employer-paid premiums for employee group health insurance are generally A. tax-deductible to the employer B. nontaxable to the employees C. both of the above D. neither of the above

B. Capitation arrangement

In Health maintenance organizations, the use of primary care physician or PCP is common as part of A. group model B. a capitation arrangement C. open enrollment D. gatekeeper system

A. elimination period

In a disability income policy, there is a period during which no benefits will be paid for illness of any kind. This period usually does not apply to addicts, only to illness. The term that describes the interim is the A. elimination period B. benefit period C. waiver period D. probationary period

D. 100%

In noncontributory group plans, how many eligible employees must be covered by the plan? A. At least 50% B. Usually 75% or more C. At least 90% D. 100%

C. Four

In order to be qualified, a long-term care policy must require assistance with how many activities of daily living (ADL's) before benefits may be paid? A. Two B. Three C. Four D. There is no minimum or maximum number required

B. Enroll within a specified eligibility period

In order to obtain group insurance without providing evidence of insurability, who do eligible individuals generally have to do? A. Submit an attending physician's statement with their group enrollment cards B. Enroll within a specified eligibility period C. Enroll within the first 90 days of employment D. All of the above

B. Is elective

Jay, who is employed by Carson Company, is assigned to work temporarily in another state. While in the other state, Jay is injured on the job. He is entitled to benefits of the Workers Compensation law in the state in which he was hired even though his injury occurred in a different state. This indicated that the workers compensation law in the state Jay was hired A. is compulsory B. is elective C. includes extraterritorial provisions D. Has a second injury fund

B. Impairment and COLA riders

Luis and Margarita Rodriguex have a family health policy that includes two riders. One rider excludes coverage for Margartia's existing diabetes. The other rider indicates that a couple may purchase additional disability income coverage at specified dates in the future without proving insurability. What two riders are attached to this policy? A. Impairment and guaranteed insurability riders B. Impairment and COLA riders C. Waiver of premium and guaranteed insurability riders D. Waiver of premium and multiple indemnity riders

D. Stop-Loss Limit

Many major medical policies include a provision whereby when expenses reach a certain dollar amount, the insured no longer shares in the costs of the expenses; the insurer pays 100% of the remaining covered charges. This is referred to as the A. maximum benefit B. benefit restoration C. coinsurance percentage D. stop loss limit

B. to subscribers who are responsible for paying the providers

Normally, Blue Cross/ Blue shield makes payments for medical expenses A. directly to the providers B. to subscribers who are responsible for paying the providers C. directly to the providers under group plans and to the subscribers under individual policies D. only to HMO's or PPO's

C. called overinsurance and can be remedied by each insurers paying proportionate benefits or a single insurer allowing the. insured to choose the policy from which benefits will be paid

Operational Provisions 3, 4, 5, and 6 deal with situations where an insured can receive more money from loss of time benefits than from working, or more for reimbursement of medical expenses than these services cost. This is A. known as fraud and allows the insurer to be relieved from paying benefits B. cause for an insurer to cancel a policy without paying the benefits for expenses incurred above actual wages or actual costs C. called overinsurance and can be remedied by each insurer's paying proportionate benefits or a single insurer allowing the insured to choose the policy from which benefits will be paid D. known as misrepresentation, and is cause for the insurer to increase premiums proportionate to the amount of insurance provided under all policies

A. Cancel the policy

Optional Provisions 1 and 2, addressing changes of occupation and misstatement of age, Kermit the insurer to do which of the following? A. Cancel the policy B. Request the insured to fill out a new application to correct previous misstatements or alter information that has changed since the application was originally submitted. C. Charge a "back-end" premium to make up for the premium the insurer would have charged had the true situation been known. D. Pay indemnities equal to the benefits that would have purchased at the premium paid had the insurer known the facts when the premium was established.

D. neither of the above

Optional provision 9, which deals with conformity to state statues, provides A. that states may revise their insurance regulations to conform to policies normally written within the individual states B. that policy provisions in conflict with state statues where the insured resides are automatically amended to conform to the minimum requirements of the law C. for both of the above D. for neither of the above

B. Social security payroll taxes

Primary support for Medicare Part A comes from A. General tax revenues B. Social security payroll taxes C. Private funding D. A combination of the above

B. 30 days from the date insurer receives the application for reinstatement

Required Provision 4 addresses reinstatement of a lapsed policy. According to this provision, when an insured applies for reinstatement and reciveves conditional receipt, how long does the insurer have to approve or deny reinstatement before the policy will automatically reinstated A. 180 days from the date the unpaid premium was due B. 30 days from the date the insurer receives the application for reinstatement C. 45 days from the date of the conditional receipt D. There is no such automatic reinstatement

B. One year from the time proof is otherwise required

Required provisions 7 indicated that except in the absence of the insured's legal capacity, if it was not reasonably possible for the insured to provide proof of loss as required in a policy, the latest time the proof of loss may be furnished is A. three years from the time proof is otherwise required B. On year from the time proof is otherwise required C. within 90 days of a final notice from the insurer D. unlimited

C. Prior Authorization

Second surgical opinions, recertification, concurrent and retrospective reviews, and outpatient/mbulatory services are all elements of cost-containment system commonly known as A. COBRA B. case management C. prior authorization D. LTC

B. Conversion generally must be within 31 days after the family coverage ends and the individual must provide evidence of insurability

Select the correct statement about converting from a family policy to an individual policy A. Usually, a conversion may be made without evidence of insurability if the individual does within 31 days after the family coverage ends B. Conversion generally must be within 31 days after the family coverage ends and the individual must provide evidence of insurability C. Generally, conversion may be made anytime within the 365 days following the individuals 19th birthday without evidence of insurability 31 days after that, the individual may convert, but evidence of insurability will be required D. Usually, no evidence of insurability is required if the individual is a full time student at a recognized insinuation or higher education and makes the conversion within 31 days of graduation

C. Present policies are more likely to pay benefits regardless of the level of care required by the insured

Select the correct statement about long term care policies A. ADLs are not generally a consideration under the policies B. Most LTC policies are guaranteed renewable ip to age 70, after which they recertifications to optionally renewable prices C. Present policies are more likely to pay benefits regardless of the level of care required by the insured D. Virtually all LTC policies require prior hospitalization before benefits will be paid

B. When employers discontinue group coverage, employees must prove they are insurable in order to convert to individual coverage

Select the correct statement below A. COBRA permits companies who have terminated employees to stop their group coverage as of the date of termination B. When employers discontinue group coverage, employees must prove they are insurable in order to convert to individual coverage C. COBRA protects dependents of employees by mandating for them the same extension and conversion proivelages available to employees covered by groups plans D. All the above are correct

B. stop-loss limit

Some major medical policies begin with basic first dollar coverage that pays up to its limits, then the insured must pay a certain dollar amount of expenses before the major medical portion steps in. What term applies to the dollar amount the insured must pay between the basic policy and the major medical coverage? A. Coinsurance percentage B. stop-loss limit C. corridor deductible D. internal limit

D. nonparticipating plan

The employees of Ace Trucking company must each pay a portion of the premium for their group insurance. This means they are members of a A. noncontributory life plan B. contributory group plan C. participating plan D. nonparticipating plan

B. Reserves

The factor in premium computation that has to do with the record keeping and statistical analysis insurance companies preform is A. Expense Loading B. Reserves C. Experience D. Policy Fees

B. elective indemnity benefit

The optional short term disability income benefit that pays a lump sum for specified injuries is called the A. hospital income benefit B. elective indemnity benefit C. supplemental income benefit D. partial disability benefit

B. health maintenance organization

The type of health care provider that provides birth the health care services and the healthy care coverage is A. Preferred provider organization B. Health maintenance organization C. Blue cross/blue shield organization D. Traditional health insurance company

B. A Franchise Policy

The type of health insurance policy most likely used to cover all students attending a large university is? A. Blanket Policy B. A Franchise Policy C. An ASO D. A self-Insured Policy

C. A reimbursement to the individual subscriber

The usual payment arrangement under a Preferred provider Organization Contract is A. a fee for each service B. A flat monthly amount for each subscriber C. A reimbursement to the individual subscriber D. Any of the above

B. Trent is the contingent beneficiary and Nancy is the primary beneficiary.

Trent Bixley is named by the insured, Nancy Bixley as the first in line to recieve the death benefit provided by Nancy's accident policy. Their daughter Elaine is named as second in line to recieve the benefit. Which statement is correct? A. Trent is the primary beneficiary and Elaine is the contingent beneficiary B. Trent is the contingent beneficiary and Nancy is the primary beneficiary. C. Nancy is the primary beneficiary and Elaine is the contingent beneficiary D. Both Trent and Elaine are primary beneficiaries.

A. 20,000

Under a credit health policy, what is the maximum amount of any accidental death benefit included? A. 20,000 B. the amount of the oringal indebtedness C. The amount of the outstanding indebtedness at any given time D. A specified multiple of the monthly loan payment

D. Temporary partial disability

Under the Workers Compensation, a disability that is a permeant physical impairment leaving the individual incapable of preforming the previous regular occupation, but capable of performing some other type of work is a A. Permanent total disability B. Permanent partial disability C. Temporary total disability D. Temporary partial disability

B. Usually, a restoration is permitted only after the insured is certified as being totally and permanately disabled

Under what circumstances do major medical policies usually provide for restoration of benefits? A. Usually, a major medical policies do not have such provisions B. Usually, a restoration is permitted only after the insured is certified as being totally and permantely disabled C. Restoration usually occurs after a specified dollar amount of benefits has been exhausted and after the insured has proved insurability D. normally, a restoration of benefits is provided only if the major medical policy is written in conjunction with a disability income policy and restoration occurs upon the insured's application for after recovering from a temporary disability

D. 31 days

What is the minimum grace period, provided in Required Provision 3, for all policies other than monthly or weekly premium policies? A. 7 days B. 10 days C. 15 days D. 31 days

A. Collateral Assignment

What term describes a situation where a policy owner transfers a potion of his or her rights in an insurance policy to another party in order to secure a debt to that party? A. Collateral Assignment B. Absolute Assignment C. Transfer Assignment D. Accumulations Assignment

Stop-Loss Limit

What term describes the concept that the insurer and the insured share in the cost of medical expenses, with the insurer bearing the greater share?

A. expense loading

When an insurer cedes part of an insured's coverage to another insurance company, retaining only part of the risk for itself, the insurer is engaging is A. expense loading B. reinsurance C. unfair discrimination D. misrepresentation

C. with the approval and signature of the insured

When may agents change a policy or waive its provisions according to Required Provision 1? A. never B. with the approval and signatures of the insured and of an executive officer of the insurance company C. with the approval and signature of the insured D. with the approval and signature of an executive officer of the insurance company

D. Designated Charges

When medical expenses policies do not state any specific dollar amount, but instead base payments upon the charges for like services in the same geographical area, benefits are designated as which of the following? A. Usual, customary and reasonable charges B. Stated charges C. Percentage of Stated Charges D. Designated Charges

b. Allows the proposed insured to look over the application carefully before completing it

Which of the following accurately describes the "free look" provision A. Allows the proposed insured to look over a policy carefully before applying for it B. Allows the proposed insured to look over the application carefully before completing it C. Allows the insured to look over the issued policy for a specific number of days and return it for a premium refund if desired D. Allows the insurance company to obtain an inspection report and medical examination on the proposed prior to issuing the policy

D. People with any life threatening condition

Which of the following are NOT eligible for Medicare coverage? A. People age 65 and older who are eligible for social security B. People age 65 and older not eligible for social security but willing to pay a monthly premium C. People of any age who have been entitled to disability benefits for 24 months D. People with any life-threatening condition

C. an insurance plan for employers with multiple branch offices or plant locations

Which of the following describes a multiple employer trust MET A. an association of employers cooperating to reduce medical costs through prevention B. an organization that handles investments for self-insured plan C. an insurance plan for employers with multiple branch offices or plant locations D. a legal entity that small employers may join to become eligible for group insurance

D. Notice provided to any authorized agent of the insurance company is considered to be proper notification to the insurer

Which of the following is not true concerning the notice of claim and claim forms according to Required Provisions 5 and 6? A. The insured must file the notice of claim within 10 days or as soon after as reasonably possible B. If the insurer fails to send the insured claims forms within 15 days after the insured gives notice of claim, the insured may submit written proof of the loss. C. Notice of the insurer may be given by a beneficiary of the insured on the insureds behalf D. Notice provided to any authorized agent of the insurance company is considered to be proper notification to the insurer

B. A written request from an applicant to an insurer requesting the insurer to issue a policy on the basis of the information in the application

Which of the following most accurately and completely describes an application? A. a form furnished by the insurer requesting certain information to become part of the insurance policy B. a written request from an applicant to an insurer requesting the insurer to issue a policy on the basis of the information in the application C. An oral request from an agent to an insurer to issue an insurance policy D. an application can be any of the above

B. Quarterly

Which of the following premium modes will result in the highest total premium? A. monthly B quarterly C. Semi-annually D. annually

A. A factory worker fractures an elbow while working overtime

Which of the following qualifies as a compensable injury under workers compensation coverage? A. A factory worker fractures an elbow while working overtime B. An employee is struck by a car and seriously injured while walking back to work following a lunch break C. A worker is involved in an auto accident while driving to work D. All of the above qualify

C. Information and privacy protection act

Which of the following represents certain consumer safeguards enacted by states and pattered after a model act developed by NAIC? A. Fair credit reporting Act B. the MIB C. Information and privacy protection act D. COBRA

B. the group insurer for the spouse of the person with the claim is secondary

Which of the following statements is NOT true concerning a coordination of benefits the situation? A. the group insurer for the person with the claim is primary B. the group insurer for the spouse of the person with the claim is secondary C. to prevent overinsurance, the secondary insurer does not pay benefits D. where children are involved, the primary group insurer is the insurer for the parent whose birthday comes first in the year

C. cost of living adjustment rider

Which of the following waives the elimination period in a disability policy? A. Impairment Rider B. Hospital conferment rider C. cost of living adjustment rider D. guaranteed insurability rider

A. Length of the waiting period

Which of the following would NOT be a likely consideration in determining premium rates for group health insurance? A. Length of the waiting period B. Maximum indemnity period C. Whether the business is a close corporation or publicly held corporation D. Degree of occupational hazard associated with the group

D. All of the above

Which part of medicare requires a premium payment by the most eligible participants? A. Part A, basic hospice insurance B. Part B, supplementary medical insurance C. Respite Care D. All of the above

D. most dental policies are included as part of health benefits package covering all medical needs

Which statement below is correct concerning dental care policies? A. Comprehensice dental care places usually pay a percentage of reasonable and customary charges for non routine treatment B. Scheduled dental policies are likely to include orthodontic care C. When orthodontics care is included in a dental police, it usually is subject to the same maximums and deductibles as other covered services D. most dental policies are included as part of health benefits package covering all medical needs

B. Concealment is withholding of information that should have been provided to an insurer

Which statement is correct? A. warranties are statements an individual believes to be true to the best of his or her knowledge B. Concealment is withholding of information that should have been provided to an insurer C. Misrepresentations are universally assumed to be material D. all of the above are correct

D. The master policy owner

With regard to group insurance, who has the responsibility to apply for coverage, provide information about the group, maintain the policy, and pay premiums? A. The agent that wrote the group coverage B. The insurer that provides the group coverage C. The individuals that make up the group D. The master policy owner