Health Insurance Study Guide
Substandard Risks
An increased risk of loss
All of the following are features of a health insurance plan purchased on the health insurance marketplace EXCEPT?
Dollar limits on essential benefits
Key person Disability Income
Premiums are not deductible to the business, but the benefits are received income tax free by the business
A medical isnruance plan in which the health care provider is paid a regular fixed amount for peoviding care to the insured and does not recieve additional amounts of compensation dependent upon the procedure performed is called...?
Prepaid plan
In Medicare prescription drug plans, step therapy refers to..?
Prior authorization
Disability Buyout Agreement
specifies who will purchase a disabled partner's interest and legally obligates that person or party to purchase such interest upon disability.
Orthodontics
treatment of natural teeth to prevent and/or correct dental anomalies with braces or appliances
Endodontics
treatment of the dental pulp within natural teeth such as a root canal
What fee is the insured required to pay to the IRO in order to have an independent review conducted?
$25 conditionally refundable
What is the maximum penalty for habitual willful noncompliance w/the Fair Credit Reporting Act?
$2500
If a person does not comply with an order issued within 2 weeks after the Commissioner has given notice, for each day that the violation continues, the Commissioner may issue a fine of up to..?
$5000
Any person who violates an insurance statue or rule of Wisconsin can be imprisoned for up to how many years?
3 years
The Commissioner obtains a restrainging order against a person who has violated an insurance law. The person continues the violation for 15 days. The person will have to pay a fine of..?
$1000
IN order to qualify for Medicaid, the applicant must
.........
What percentage of individually owned disability income benefits is taxable?
0%
If group coverage ends, coverage may continue or converted to an individual policy if a person has been insured under that contract for at least..?
3 months
If the Commissioner issues an order without having conducted a hearing, the person aggrieved by the order may demand a hearing within how many days after the order was mailed?
30 days
How long is open enrollment period for Medicare supplement policies?
6 months period that guarantees the applicants the right to but medigap once they first sign up for Medicare Part B
If the insurer failed to pay a claim within the required period of time, all overdue payments will be charged an annual interest of..?
7.5%
Contributory Plan
75% of eligible employees muct be included in a contributory plan
An insurer plans to discontinue a specific type of group health insurance coverage. How much prior notice must the insurer give each employer and plan participant?
90 days
If the Commissioner disapproves a form used by an insurer, the use of the form must be discontinued within the maximum of how many days?
90 days
If a LTC policy containes a return of premium feature, and the insured dies, the insurer will return...?
A certain percentage of the premiums paid
Which of the following losses will be covered by a group medical expense policy?
A pre-existing condition
A LTC policyholder requests that his policy be canceled. Which of the following is true?
A prorated refund will be issued
Which of the following would be considered an example of incorporation by reference in insurance contracts?
A rate amendment is later made part of the original policy
Preferred Risk
A reduced risk of loss and are covered at reduced rate. Nonsmokers would be an example of this.
All of the following are correct about the required provisions of a health insurance policy EXCEPT..?
A reinstated policy provides immediate coverage for an illness
Material Representation
A statement, that if discovered, would alter the underwriting decision of the insurance company
Every producer must maintain a place of business in this state....
Accessible to the public
What are the four elemnts to an insurance contract?
Agreement (offer & acceptance) Consideration Competent Parties Legal Purpose
How is the Commissioner of Insurance placed in office?
Appointed by the govenor
Under a Key Person disability income policy, premium payments
Are paid by the business/employer
Occassional visits by which of the following medical professionals will NOT be covered under LTC's home health care?
Attending physician
Standard Risk
Average exposures and may be insured at standard rates and premiums
How is the amount of Social Security disability benefits calculated?
Based upon the workers Primary Insurance Amount (PIA), which is calculated from their Average Indexed Monthly Earnings over their highest 35 years
Which of the following is NOT a typical type of LTC coverage?
Child day care
In order for an insurance contract to be legally binding, it must have all of the following elements except?
Consideration
All of the following are essential elements of a contract except..?
Consideration (Not Sure)
An employee dies having 6 quarters of coverage during the previous 13-quarter period. What status of coverage does the employee have under Social Security?
Currently insured
Group disability income insurance premiums paid by the employer are
Deductible by the employer as an ordinary business expense
The main purpose of ERISA is to ensure that..?
Employees receive the pension and other benefits promised by their employers.
Which of the following is a statement promoting an insurer and its policy made by an individual, group, society, association, or other organizations, which makes no reference to experience under the policy?
Endorsement
In heath underwriting, it would be inappropriate to decline a risk using any of the following factors EXCEPT...?
Mental Illness
In contrasting stock insurers with mutual insurers, which statement is true?
Stock insurers are owned by the shareholders and issue nonparticipating policies
When a group disability insurance policy is paid entirely by the employer, benefits paid to disabled employees are
Taxable income to the employee
In health insurance, the policy its self and the insurance application form what?
The entire contract
Periodontics
Treatment of the surrounding and supporting tissue of the teeth such as treatment for gum disease
Restorative Care (Dental)
Treatments, which restore functional use to natural teeth such as fillings or crowns.
Unilateral Contract
only one of the parties to the contract is legally bound to do anything
Prosthodontics
replacement of missing teeth with artificial devices like bridgework or dentures
Which of the following meets the insured's personal needs, and is provided by nonmedical personnel?
Custodial care
When the Commisioner examines an insurer, who pays the examination costs?
Examinees
Under HIPPA portability which of the following are not protected under required benefits?
Groups of one or more
Time Limit on Certain Defenses provision
Identical to Incontestable Clause in Life policy.
Utmost Good Faith
Implies that there will be no fraud, misrepresentation or concealment between the parties.
All of the followwing statements about Medicare part B is correct EXCEPT..?
Its a compulsory program
Which of the following time periods is the general enrollment period for Medicare Part B?
Jan 1 - Mar 31
Which of the following statements is NOT correct regarding Medicare?
Medicare Advantage must be provided through HMOs
Under what condition are group disability income benefits received by an employee NOT taxable as income?
When the benefits received are equal or less than the employee's percentage of the contribution
A producer CANNOT act as an agent of an insurer without which of the following?
An appointment by the insurer
All of the following are features of catastrophic plans EXCEPT?
High premiums
Which of the following types of health policies cover medical and hospital expenses, and have deductibles, coinsurance and high maximum limits?
Major Medical?
In cases where a covered employee is eligible for Medicare benefits to treat end stage renal disease with dialysis for kidney transplant, which of the following is correct?
Medicare is the secondary payer during the first 30 months of treatment
If the Department issues a cease and desist order, that means the insurer must do which of the following?
Prevent themselves (insurer) and the agent from further violating laws for transacting insurance
In reference to the standard Med Supp benefits plans, what does the term standard mean?
All providers will have the same coverage options and conditions for each plan
In reference to the standard Medicare Supp benefits plans, what does the term standard mean?
All providers will have the same coverage options and conditions for each plan
How long must an agent keep records of disability policy replacement?
`
To comply with timely payment of claims provision, insurers must pay a claim within how many days of receiving proff of loss?
30 days
When the appt. of an individual agent is terminated, the insurer must notify the Office of Commissioner with appropriate forms within how many days after the termination date?
30 days
What is the maximum period of coverage for most short term care policies?
36 months
Who determines whether an insurer's operations are finacially sound and that the insurer remains solvent?
Guaranty Association
Which statement regarding insurable risk is NOT correct?
Insureds cannot be randomly selected
The law of large numbers is best defined as a large number of people w/similar exposures to loss resulting in actual losses being..?
More predictable
If an insured misstated his age on an application for health insurance, the insurance company has the right to...?
The benefit amount payable under the policy will be adjusted to the insured's correct age
Declined Risks
The underwriter feels that the applicant is too high at risk, the applicant may be declined
Which of the following is true regarding benefits paid to disabled employees?
They may be subject to taxation if the premium was paid by the employer