mass exam 3

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 days (days 21 to 100 require daily copayment)

COBRA applies to companies with how many employees

20 or more

Nonqualified distributions from an MSA are included in the employee's gross income and subject to a penalty tax of

20%

A policy deemed to be approved by the commissioner if it has been on file for at least how many days

30 days

under COBRA, for events such as death of employee, or divorce, how long is the period for dependents

36 months

Health benefits plans are prohibited from including waiting periods that exclude coverage for more than how many months

4 months

terminated employees under COBRA must exercise benefits within how many days

60 days

cost of living adjustment

A disability insurance provision to increase monthly benefits

Estoppel

A legal impediment to denying a fact or restoring a right that has been previously waived.

Substandard Risk

An applicant or insured who has a higher than normal probability of loss, and who may be subject to an increased premium.

Conformity with State Statutes

Any policy provision that is in conflict with state statutes in the state where the insured lives at the time the policy is issued is automatically amended to conform with the minimum statutory requirements of that state

Under a Key Person disability income policy, premium payments

Are made by the business and are not tax-deductible.

Custodial Care

Care that is rendered to help an insured complete his/her activities of daily living.

Group disability income insurance premiums paid by the employer are

Deductible by the employer as an ordinary business expense.

Attending Physician's Statement (APS)

Designed to obtain more specific information about a particular medical problem revealed in the application or during the medical examination

An insured has medical insurance coverage through 2 different providers, both covering the same expenses on an expense-incurred basis. Neither company knows in advance that the insured has coverage through any other insurers. The insured submits a claim to both insurers. How should the claim be handled?

Each insurer should pay a proportionate share of the claim

retrospective review

Employers and insurers can evaluate the utilization review process and the effectiveness of the professionals involved in large claims. These reviews include hospital bill audits.

Which entity must approve all Medicare supplement advertisements?

Insurance Commissioner or Director

Buy-sell policy (benefits)

received income tax free

Paul is a producer in Vermont and wants to become a producer in Massachusetts. The Department will waive certain examination requirements, provided that Vermont would waive these same requirements if a Massachusetts producer sought licensure in Vermont. What term is used to describe this phenomenon?

reciprocity

Preferred Risk

reflect a reduced risk of loss and are covered at a reduced rate (nonsmokers)

Standard Risk

reflect average exposures and may be insured at standard rates and premiums

Waiver of Premium Rider

should the owner be disabled and cant earn an income, after 6 months, all premiums will be paid by the insurer during the disability period; After 6 months, the premiums will be repaid

concurrent review

the insurance company will monitor the insured's hospital stay

Provided they are of a certain age, residents of Massachusetts are required to maintain minimum creditable coverage. What age?

18

for any qualifying event under COBRA, coverage us extended up to how many months

18 months

The relation of earnings to insurance provision allows the insurance company to limit the insured's benefits to his/her average income over what period of time?

2 years

An insured buys an individual long-term care policy and is not satisfied with the provisions. Within how many days will the insured be able to return the policy for a full premium refund?

10 days

Accidental Bodily Injury

Unplanned, unforeseen traumatic injury to the body.

The Pregnancy Discrimination Act specifically prohibits pregnancy discrimination by employers with the minimum of how many employees?

15

Yearly Wellness Visit (Part B)

preventative visit available during first 12 months

Which statement regarding insurable risks is NOT correct? a)An insurable risk must involve a loss that is definite as to cause, time, place and amount. b)Insureds cannot be randomly selected. c)Insurance cannot be mandatory. d)The insurable risk needs to be statistically predictable.

Insureds cannot be randomly selected. (Granting insurance must not be mandatory, selecting insureds randomly will help the insurer to have a fair proportion of good risks to poor risks. All other statements are true.)

Which entity has the authority to make changes to an insurance policy?

Insurer's executive officer

Reciprocity licensure

Massachusetts permits nonresident licensure for all nonresidents of the state whose home states issue a similar nonresident license to Massachusetts residents living in that state

outpatient treatment of mental illness (part b)

Medicare covers outpatient treatment of an approved condition in a doctor's office or other health care provider's office or hospital outpatient department (inpatient is covered under Part A)

Home Health Visits (part b)

Medicare will pay for home health services as long as these services are recommended by the insured's doctor and the insured is eligible.

Premium payments for personally-owned disability income policies are

Not tax deductible.

Under most dental plans, what limitations are posed for denture replacement?

Once every 5 years

Outpatient Hospital Services (part b)

Part B covers outpatient hospital services received for diagnosis and treatment, such as care in an emergency room, outpatient clinic, or a hospital

Medical Reimbursement Benefit

Pays medical expenses for nondisabling injuries.

All of the following are covered by Part A of Medicare EXCEPT )Physician's and surgeon's services. b)In-patient hospital services. c)Post-hospital nursing care. d)Home health services.

Physician's and surgeon's services.

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.

insurance information and privacy act

Sets up procedures for consumer reporting agencies. does not apply to information collected from public records of a governmental authority

Notice Regarding Replacement

Signed by both the applicant and the producer. must inform the applicant of the 30 day free look provision of the replacing policy

If an insurer becomes insolvent, who would pay benefits to policyholders?

The Guaranty Association

Apparent Authority

The appearance or the assumption of authority based on the actions, words, or deeds of the principal or because of circumstances the principal created.

Aleatory Contract

The exchange of value is unequal.

An insured purchased a noncancellable health insurance policy 1 year ago. Which of the following circumstances would NOT be a reason for the insurance company to cancel the policy? a)The insured is in an accident and incurs a large claim. b)The insured does not pay the premium. c)The insured reaches the maximum age limit specified in the policy. d)Within two years of the application, the insurer discovers a misrepresentation.

The insured is in an accident and requires large claim.

Prospective Review

The physician can submit claim information prior to providing treatment to know in advance if the procedure is covered under the insured's plan and at what rate it will be paid.

Which of the following provisions must be included on the first page of a Medicare supplement policy, which states the insurers right to change premium amounts?

The renewal provision, also known as continuation provision, must be included on the first page of medicare supplement policies.

In insurance policies, contract ambiguities are automatically ruled in the favor of the insured. What privilege does the insurer have in order to balance this?

The right to determine the wording of a policy

Accidental Means Clause

This clause will cover accidents only if the cause is unintentional and unforeseen

A nonresident producer who moves from one state to another state or a resident producer who moves from the commonwealth to another state must file a change of address and provide certification from the new resident state

Within 30 days of the change of legal residence

If a producer has administrative action taken against his license, he must report such action

Within 30 days of the final disposition on such action.

Jason is insured under his employer's group health insurance. He splits the cost of the premiums with his employer. This is an example of

a contributory plan

What is the amount a physician or supplier bills for a particular service or supply?

actual charge

Twisting

agent persuades an insured to cancel, lapse, or switch policies, even when it's to the insured's disadvantage.

Implied Authority

an agent's authority to do things not specifically authorized in order to carry out express authority

Declined Risks

applicants who are rejected

Which of the following entities is responsible for paying the producer's appointment renewal fee?

appointing insurer

If during the underwriting process an insurer obtains personal information about an applicant from the applicant, when must the insurer provide notice of its information practices?

at the time of policy delivery

Doctor Services (Part B)

covered by part B. includes surgical services, diagnostic tests and x-rays, medical supplies furnished in doctors office, and office nurse service.

What is the difference between the Medicare approved amount for a service or supply and the actual charge?

excess charge

An insurance company has published a brochure that inaccurately portrays the advantages of a particular insurance policy. What is this an example of?

false advertising

What option allows the insured to periodically increase benefit levels without providing evidence of insurability?

guarantee of insurability

A new employee who meets HIPAA eligibility requirements must be issued health coverage on what basis?

guaranteed

Guarenteed Insurability Rider (GIR)

protects the insureds right to buy more coverage in the future without the need to prove good health

Insurers may change which of the following on a guaranteed renewable health insurance policy?

rates by class

Reinstatement

if premium has not been paid by end of grace period, the policy will lapse. coverage automatically reinstated if not refused within 45 days from the date the conditional receipt was issued. accidents covered immediately.

coordination of benefits provision

in group health insurance is designed to prevent overinsurance and the duplication of benefits if one person is covered under more than one group health insurance plan.

cost-saving services (aka case management provisions) include

include services like preadmission testing, second opinions regarding surgery, preventative care, risk sharing

the outline of coverage must provide

information about the insurance company, the policy number, important features of the policy, and explain the right to return the policy for a refund

Adhesion

insured has little to say about policy provisions

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

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

insuring clause

Which of the following is the basis for a claim against an insurance policy?

loss

A health insurance plan which involves financing, managing, and delivery of health care services and involves a group of providers who share in the financial risk of the plan or who have an incentive to deliver cost effective service, is called

managed care plan

Part B financed by

monthly premiums paid by insured, and federal government

Under the Fair Credit Reporting Act, individuals rejected for insurance due to information contained in a consumer report

must be informed of the source of the report

medical savings accounts are only available to groups of how many employees?

no more than 50

Bethany studies in England for a semester. While she is there, she is involved in a train accident that leaves her disabled. If Bethany owns a general disability policy, what will be the extent of benefits that she receives?

none

The Commissioner may issue a temporary insurance producer license without requiring an examination for a period

not to exceed 180 days

An insured has health insurance that covers them at work and at home. This policy was written on what basis?

occupational

prescription drugs (part b)

only medicines that are administered in a hospital outpatient department under certain circumstances. otherwise, insured under part B will have to pay 100%, unless covered by part D.

Part A financed by

payroll taxes (FICA)

community rating

premiums based on overall claims experience experience of the insurance company (individual policy)

After the elimination period, a totally disabled insured qualified and started receiving benefits from his disability income policy that has a waiver of premium rider. What will most likely happen to the premiums paid into the policy during the elimination period?

premiums will be refunded

Experience Rating

the premiums are determined by the experience of this particular group as a whole - helps employers with low claims because they get lower premiums (group policies)

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