Chapter 12 life insurance test

A corporation can be considered a " small-group employer" if it has at least one and a maximum of how many employee's? A) 20 B) 30 C) 40 D) 50

50 ( "small group employers" means any person , firm, corporation, partnership, or association that is actively engaged in business that has no more than 50 eligible employees)

Most HMOs operate through what type of system?

A group enrollment system either at their place of employment or as a member of an association (Most HMOs operate almost exclusively through a group enrollment system, in which each member pays a fixed monthly premium, whether or not they have used the services of the HMO in the last month)

What does MEWA stand for?

Multiple employer welfare associations

At what age are individuals become INELIGIBLE for Florida Health Kids Coverage? A) 21 B) 15 C) 16 D) 19

19 ( Only children under the age of 19 are eligible for Florida Healthy Kids coverage

Long term care benefits are triggered when the insured is unable to perform at least A) 1 ADL's B) 2 ADL's C) 3 ADL's D) 4 ADL's

2 ADL's ( Long term care benefits are triggered wen the insured is unable to perform at least 2 ADL's)

If a parent would like to enroll a child over the ane of 5 into the Florida Healthy Kids Program, their family income must be under what percentage of the federal proverty level?

200% ( To qualify for the Florida Healthy Kids program, a child's family's income must be below 200% of the federal poverty level. If a child's family's income exceeds 200%, they are only eligible until the age of 5)

In order for an employee to be eligible for small group insurance, he/she must work at least how many hours per week?

25

In order for an employee to be considered eligible for small group insurance, he/she must work at least how many hours per week?

25 ( "eligible employee" means an employee who works full time, having a normal work week of 25 or more hours, and who has met any applicable waiting-period requirements or other requirements)

If an insurance company offers Medicare supplement policies, it must offer which of the following plans? A) A B) A&B C) B-N D) A-D

A ( An insurance company must make available to each applicant a policy form offering the basic core benefits (Plan A) if it will offer any Medicare Supplement policies. An insurance company does not have to issue all or any of the plans B through N)

Most of HMOs operate through what type of system?

A group enrollment system either at their place of employment or as a member of an association ( Most HMOs operate almost exclusively through a group enrollment system, in which each member pays a fixed monthly premium, whether or not they have used the services of the HMO that month)

Which statement best describes a Multiple employer welfare arrangement?

A joining together by employers to provide health benefits for the employee ( A MEWA provides benefits for a number of member groups)

When must an insurance company present an outline of coverage to an applicant for Medicare supplement policy?

At the time of application ( For Medicare supplement policies, the insurance company must present an outline of coverage to all applicants at the time of the application)

When must the Medicare Supplement Buyer's Guide be presented?

At the time of the application (Issuers of accident and sickness policies which provide hospital or medical expense coverage on the expense incurred or indemnity basis to the person eligible for Medicare by reason of age, must provide to that applicant a Medicare supplements Buyers Guide. Except for direct response issuers, delivery of the buyers guide must be made at the time of the application, and the insurance company must obtain a receipt)

The First Street Church plans to sponsor a summer camp for the youth of their congregation. They would like to purchase insurance that would pay benefits should one of the youth get injured while participating in the camp activities. The type of policy they would likely need is a/an? A) Accidental death and dismemberment B) Limited Accident C) Blanket D) limited sickness

Blanket ( A policy that covers all of the participants without naming them individually is a blanket policy)

A group policy used to provide accident and health coverage on a group of persons being transported by a common carrier, without naming the insureds persons individually is called?

Blanket policy

HMOs that contract with outside physicians to provide health care service to their subscribers compensate those providers on a

Capitation basis (HMOs generally pay the provider a fixed amount per subscriber in exchange for the medical services agreed upon, called a capitation basis)

A 70-year-old individual who bought a Part B Medicare policy 2 months ago just began kidney dialysis treatments this week. The individual is now applying for a Medicare supplement policy, Which begins in 8 months. Which of the following could the insurer do to avoid paying for the dialysis? A) Charge a higher premium B) Declare a pre-existing condition C) Permanently exclude coverage for dialysis D) Deny the supplement policy

Declare a pre-existing condition ( If an applicant is aged 65 or greater applies for Medicare supplement coverage while covered under Medicare Part B insurance, an insurer cannot alter the price of coverage based on prior claims experience or health status, provided that the application was made during the first 6 months of Part B coverage. The insurer may however exclude benefits during the first 6 months based upon a pre-existing condition for which the policyholder received treatment during the 6 months before it became effective)

Which types of insurance companies marketing long-term care insurance coverage must establish procedures to assure that any comparison of policies by its agents will be fair and accurate?

Every company is required to establish marketing procedures ( Every insurer marketing long-term care coverage must establish marketing procedures to assure that any comparison of its policies by its agents is accurate and fair. Companies must also have marketing guidelines to ensure that excessive insurance is not sold or issued to clients)

Which of the following was designed to ensure continued access to affordable health insurance coverage for employees of small employers, their dependents, and other qualified beneficiaries not currently protected COBRA?

Florida health insurance Coverage continuation ACT ( The purpose and intent of the Florida Health insurance coverage continuation Act is to ensure continued access to affordable health insurance coverage for employees of small Employer's, their dependents and other qualified beneficiaries not currently protected by the consolidated omnibus budget reconciliation act [COBRA]).

All of the following would be legal activities for an HMO to engage in EXCEPT? A) dental services B) Medical services C) Health education D) Health insurance solicitation

Health insurance solicitation ( An HMO may not engage in any services that do not fall in Florida's definition of "comprehensive health care services")

Which of the following entities must approve all Medicare supplement advertisements?

Insurance commissioner or Director ( An insurance company must provide a copy of any Medicare supplement advertisement intended to be used in this state to the insurance director for review or approval)

Which of the following does NOT describe hospice care? A) It provides care in a home-like setting B) It provides care to terminally ill people. C) It provides care to people with life expediencies of 1 to 2 years D) It provides continuous care

It provides care to people with life expediencies of 1 to 2 years ( Hospice provides short-term, continuous care in a home-like setting to terminally-ill people with life expediencies of 6 months or less)

A state program of medical assistance for needy persons that is administered under federal guidelines is?

Medicaid ( Medicaid is administered by each state according to Federal guidelines and is financed from both state and federal funds. Each state may establish its own standards to determine who is indigent and what medical services are provided, subject to the minimum standard established by the Federal government)

All of the following are required provisions in all individual health insurance policies delivered in this state EXCEPT? A) Misstatement of age B) Entire contract C) Grace period D) Reinstatement

Misstatement of age (Misstatement of age is an optional health insurance policy provision, meaning it may be included in the policy at the option of the insurer)

Which of the following factors would be an underwriting consideration of a small employer carrier? A) Claims experience B) health status C) Medical history D) Percentage of participation

Percentage of participation ( Coverage under a small employer health benefit plan is generally available only if at least 75% of eligible employees elect to be covered)

A medical insurance plan in which the health care provider is paid a regular fixed amount for providing care to the insured and does not receive additional amounts of compensation depending upon the procedure is called?

Prepaid plan ( Under a prepaid plan, the health care providers are paid for services in advance, whether or not any services have been provided. The amount paid to the provider is based upon the projected annual cost as determined by the provider)

Which of the following is NOT specifically prohibited by state law as an unfair-trade practice? A) Using misleading representations to induce uncalled for action by the insured B) Using incomplete comparisons of policy to induce uncalled-for action by the insured C) Failing to disclose that the solicitations of an insurance contract are the result of a marketing method D) Reducing the premiums paid by employers by group insurance based on loss experience

Reducing the premiums paid by employers by group insurance based on loss experience ( Insurers are permitted to lower the premiums of employer's group insurance because of loss experience. This is called experience rating. All the other practices would be considered unfair trade practices)

Health plan insurers are prevented from collecting genetic information for underwriting purposes or limited in their requests for genetic tests by? A) Underwriters' risk classification standards B) The genetic Anti-Discrimination Act C) The Generic Information and Nondiscrimination Act D) Individual insurers' underwriting standards

The Generic Information and Nondiscrimination Act ( The genetic information and Nondiscrimination act of 2008 [GINA] limits what requests a health plan insurer can make regarding testing, and prohibits the collection of genetic information for underwriting purposes)

Which of the following does NOT have to be disclosed in a long-term care policy (LTC) A) the meaning of the terms " reasonable" and "customary" B) Any limitations or conditions of eligibility for LTC benefits C) Any riders or endorsements D) The aggregate amount of premiums due

The aggregate amount of premiums due ( All LTC policies must disclose and explain the renewability provisions.

What type of information is NOT included in a certificate of insurance? A) The policy benefits and exclusions B) The procedures of the filling a claim C) The length of coverage D) The cost the company is paying for monthly premiums

The cost the company is paying for monthly premiums

In a group policy, who is issued a certificate of insurance?

The individual insured ( the certificate tells what is covered in the policy, how to file a claim, how long coverage will last, and how to convert the policy to an individual policy)

An insurer hires a representative to advertise its company at a local convention. The representative lies about the details of some of the policies, in an attempt to secure more business for the company. Who is responsible for the representative's claims?

The insurer ( An insurer is completely responsible for advertisements regarding its company, regardless of who creates, presents or distributed the material)

An insurance advertisement exaggerates the benefits of an insurance policy, due to human error at the insurer's advertising agency. Who will the department of insurance hold responsible for the exaggeration A) The advertising agency B) The person who made the error C) The insurer D) Inadvertent errors are not subject to any penalties

The insurer ( Insurance companies must adhere to strict advertising requirements. the insurer whose policies are depicted is ultimately responsible for its advertisements)

An individual purchased a Medicare supplement policy in March and decided to replace it 2 months later. His history of coronary heart disease is considered a pre-existing condition. Which of the following is true? A) In replacement, pre-existing conditions must be waived, so sickness relating to coronary heart disease would be covered under the policies effective date B) Because this is a new policy, the pre-existing waiting period starts over C) The pre-existing waiting period fulfilled in the old policy will be transferred to the new policy, the new one picking up where the old one left off D) Coronary artery disease coverage will be permanently excluded from the new policy

The pre-existing waiting period fulfilled in the old policy will be transferred to the new policy, the new one picking up where the old one left off (When an replaces one Medicare supplement policy with another, the pre-existing conditions waiting period does not start over. All types of waiting and elimination periods does not start over. All types o waiting and elimination periods are carried over, not restarted, since that time was served with the original policy)

Which of the following are true of MET's?

They allow several small employers to purchase less expensive insurance together ( Those small employers who cannot fully qualify for group health insurance band together for the purpose of buying insurance)

Which of the following is true regarding Medicare Supplement Policies?

They must be guaranteed renewable (Each Medicare Supplement policy must be at least Guaranteed renewable)

Long-term care policies require that in addition to the applicant, at least one person must be designated in the policy. What is the role of the designated person? A) To receive notice of policy lapse or termination B) To receive policy benefits if the insured is deceased C) To pay the premiums on the policy D) To cosign the policy application

To receive notice of policy lapse or termination ( An individual long-term care policy cannot be issued until the insurer has received from the applicant, either a written designation or at least 1 person, in addition to the applicant, who is to receive notice of lapse or termination of the policy for nonpayment of premium)

When do HMO's file reports of their activities to the department?

Within 3 months of the end of the fiscal year (Each HMO is required to file a report of its activities within 3 months of the end of each fiscal year. The department may require reports more frequently if it is deemed necessary)

In individual health insurance coverage, the insurer must cover a newborn from the moment of birth, and if additional premium of payment is required, how many days should be allowed for payment?

Within 30 days of birth ( The insured must notify the insurer of a newly born dependent, and if additional payment is required, pay within 30 days)

under florida health insurance policy, medical coverage of a newborn begins?

at birth ( Coverage for a newborn begins at birth in the state of Florida)

A long term care shopper's guide must be present at which point? A) prior to the time of application B) At the time of application C) Between the completion of the application and the delivery of the policy D) at the time of policy delivery

prior to the time of application ( A long-term care insurance shopper's guide must be provided in the format developed by the National association of insurance commissioners (NAIC). The shoppers guide must be presented to the applicant prior to completing the application)

When can a long-term care policy deny a claim for losses incurred because of a pre-existing condition? A) within 6 months of the effective date of coverage B) within 12 months of the effective date of coverage C) at any time D) at no time

within 6 months of the effective date of coverage ( A LTC policy cannot deny a claim for losses incurred more than 6 months from the effective date of coverage because of pre-existing conditions)

The Florida Health Insurance Coverage Continuation Act requires insurers that sell health plans to small employers to offer in those plans to elect to continue coverage, without providing evidence of insurability, to employees who lose their coverage and are unable to replace it. The premium rate for this coverage may NOT exceed? A) The regular group rate B) 102% of the regular group rate C) 115% of the regular group rate D) 200% of the regular group rate

115% of the regular group rate ( The coverage may be extended for a period of up to 18 months at a rate not to exceed 115% of the regular group rate)

At what point must an Outline of Coverage be delivered?

At the time of the application or upon delivery of the policy ( An outline of coverage must be delivered at the time of the application or upon delivery of the policy)

All small employer group health plans, in order to comply with the requirements of the Florida employee health care access act, must be issued on what basis?

Guaranteed issue ( A small group plan must be issued on a guaranteed-issue basis, which means an insurance policy must be offered to an employer, employee, or dependent of the employee, regardless of health status, pre-existing conditions or claims history)

When does Medicare cover nursing home care?

Only if it is part of treatment for a covered illness or injury ( Medicare will NOT cover long-term care or nursing home care unless it is part of the treatment for a covered illness or injury)

Which of the following it NOT an unfair Trade Practice under Florida state law with regard to HMO plans? A) Unfair claim settlement practices B) Failure to maintain claim handling procedures C) Twisting D) Operating an HMO on a closed-panel basis

Operating an HMO on a closed-panel basis (Florida law allows HMOs to operate as either open-panel or closed-panel)

a long-term shopper's guide must be presented at what point?

Prior to the time of application ( A long-term care insurance shoppers guide must be provided in the format developed by the National Association of Insurance Commissioners [NAIC]. The shoppers guide must be presented to the applicant prior to completing the application).

An insurer offers a policy very similar to Medicare, although it differs slightly. An agent tells an applicant that the policy is Medicare, since the policies are so similar anyway. Which of the following is true?

This practice is ILLEGAL ( A policy may not be advertised as Medicare supplement, Medigap, or Medicare Wrap around unless the policy is in full compliance of the law under such labels. In this insurance, the insurer misrepresented the policy, which is an illegal practice)

Coverage of newborn children includes all of the following EXCEPT: A) Birth abnormalities B) Congenital defects C) Costs associated with prematurity D) Transportation costs up to $3,000 if medically necessary

Transportation costs up to $3,000 if medically necessary ( coverage includes injury or sickness, congenital defects, physical abnormalities, or prematurity, and transportation costs of up to $1,000 if medically necessary)

A group blanket health policy is best suited for which of the following? A) A manufacturer B) a large family C) A summer camp D) A small employer

A summer camp ( group blanket health insurance polices are meant to cover members of a group or association without evidence of insurability. Coverage is usually limited to loss from specific causes)

Which of the following groups would probably be covered by blanket insurance? A) A large family B) A publishing company C) people who obtain temporary insurance D) A university's sports team

A university's sports team ( A blanket policy covers members of a particular group when they are participating in a particular activity. Such groups include students, campers, passengers on a common carrier., or sports teams. Often the covered individuals name is not known because individuals come and go. Unlike group health insurance, the individuals are automatically cover, and they do not receive a certificate of insurance)

Who must sign the notice regarding replacement?

Both the applicant and the agent ( Before issuing a replacement policy, the insurer must furnish the applicant with a notice regarding replacement, which must be signed by both the applicant and the agent)

When a person applies for Medicare supplement insurance, whose responsibility is it to confirm that the applicant does not already have accident or sickness insurance already in force? a) Federal government b) Agent c) Insurer d) State government

Insurer ( Although it is illegal for an application to intentional misrepresent himself in an insurance application, it is the insurer's ultimate responsibility to make sure that the applicant does not already have another accident or sickness policy in force)

Every insurer marketing Long-Term Care insurance must establish marketing procedures to ensure all of the following EXCEPT A) Comparisons of policies are fair and accurate B) Excessive insurance will not be sold C) Every reasonable efforts is made to identify an applicants other insurance D) LTC policies are marketed effectively to prospective insureds

LTC policies are marketed effectively to prospective insureds ( All insurers marketing long-term care policies must establish these procedures. Additionally, companies must have marketing guidelines to insure that excessive insurance is not sold or issued)

All of the following statements describe a MEWA EXCEPT? A) MEWAs are groups of at least 3 employers B) MEWAs can be sponsored by insurance companies C) MEWA employers retain full responsibility for any unpaid claims D) MEWAs can be self-insured

MEWAs are groups of at least 3 employers ( MEWAs are groups of at least 2 employers who pool their risks to self-insure. MEWAs can be sponsored by an insurance company, an independent administrator, or another group established to provide group benefits for its participants)

Which of the following statements is correct? A) Medicare does not pay for nursing home care in any case B) Medicare will cover nursing home care if it is part of the treatment for a covered illness C) Care needed because of aging is covered by medicare, but not by Medicare supplements D) Care needed because of aging is covered by Medicare

Medicare will cover nursing home care if it is part of the treatment for a covered illness ( Medicare will cover nursing home care if it is part of the treatment for a covered injury or illness, but care needed because of aging is not covered by Medicare or Medicare supplements. Medicare and Medicare supplements pay for skilled nursing care, but the coverage is limited. Medicaid does pay for nursing home care, but it provides coverage only for those who qualify with low income and low assets)

In a long-term care policy, pre-existing condition limitations? A) are not permitted B) Must appear as a separate paragraph and be clearly labeled C) Apply to 12 months from the effective date of coverage D) Never have specific exclusions

Must appear as a separate paragraph and be clearly labeled ( if there are any limitations in the policy with respect to pre-exisiting conditions these limitations must appear in a separate paragraph in the policy labeled " pre-existing condition limitations". A long term-care policy cannot deny a claim for losses incurred more than 6 months from the effective date of coverage because of a pre-existing condition)

A long-term care insurance shoppers guide must be provided in the format developed by which of the following? A) NAIC B) Office of insurance regulations C) Director D) Medical information Bureau

NAIC ( A long-term care insurance shoppers guide must be provided in the format developed by the National Association of insurance commissioners [NAIC]. The shopper's guide must be presented to the applicant prior to completing the application)

When may an insurer require an insured to provide genetic information? A) Upon policy renewal B) When establishing insurability C) Only during the underwriting process D) Never

Never ( Insurers are prohibited from requesting a person or a relative of a person to supply generic information)

Any policy of health insurance that provides coverage for maternity care must also cover the services of all of the following EXCEPT? A) Midwives B) Licensed birth centers C) Nurse-midwives D) None of the above. All are true

None of the above. All are true (Any policy of health insurance that provides coverage for maternity care must also cover the services of certified nurse-midwives, midwives and services of licensed birth centers)

Shortly after a replacement transaction on a Medicare Supplement policy, the insured decided to cancel the policy, but it unsure whether the free-look provision applies. The insured can find this information in the?

Notice regarding replacement (The notice Regarding Replacement must inform the applicant of the 30-day free-look provision of the replacing policy)

Which document helps ensure that full and fair disclosure is provided to the recipient of a policy? A) Outline of coverage B) Benefit of limitations C) Policy Summary D) Statute of limitations

Outline of coverage ( The outline of coverage is created to ensure full and fair disclosure to the recipient of a new policy. This document can be released at any time of the application or upon delivery of the policy)

Which of the following groups would most likely be covered under a blanket accident policy? A) office workers for a retail business B) Factory workers at the automobile assembly plant C) Independent contractors who work for a general contractor D) Students at a public school

Students at a public school (Blanket insurance is issued on those groups that have members that are constantly changing)

Which of the following is NOT required to be stated in the outline of coverage provided with long-term care policies? A) The policy number B) The right to return the policy for a refund C) Basic information about the insurance company D) basic information about supplementary policies

basic information about supplementary policies ( The outline of coverage must follow the standard format in the insurance regulations. It must provide information about the insurance company, the policy number, important features about the policy, and Explain the right to return the policy for a refund).

When a child reaches the limiting age of a health insurance policy of the insured parent, and has an intellectual or physical disability, the insurer ma require proof that the child? A) Is incapable of self-sustaining employment because of the disability B) Is chiefly dependent upon the policyholder for support and maintenance C) Qualifies for total disability benefits D) A&B

A&B (The laws prohibit an insurance company from terminating coverage on a dependent who is and continues to be incapable of self-sustaining employment because of an intellectual or physical disability, and chiefly dependent upon the policyholder or subscriber for support and maintenance)

Which of the following Medicare supplement plans would be available to a reasonably healthy 9-year old? A) A only B) A-C only C) A-N D) K&L

A-N (All Medicare supplement plans ( A-N) must be made available to qualifying applicants, regardless of age)

Before starting operations as an HMO, the organization must meet which of the following requirements? A) Obtain a certificate of authority from the insurance department B) Obtain a valid health care provider certificate from the department of health and rehabilitation services C) Make a deposit of $10,000 to the rehabilitation administration expense fund D) All of the above

All of the above ( The requirements to start an HMO in Florida include all of the above, as well as other requirements as stated in the statutes)

A child is dependent upon her parents for support because of a physical disability. Coverage may be continued beyond a normal limiting age when the child?

Is incapable of self-sustaining employment ( Coverage beyond the normal limiting age may continue if a handicapped child is incapable of self-sustaining employment)

An insured under a group health plan has a dependent child who has an intellectual disability. When the child was enrolled in the insured's policy, the insurer offered coverage at a much higher rate than for other dependents. Which of the following is true?

It is considered illegal discrimination ( Discrimination against handicap dependents is prohibited. Health insurers cannot refuse coverage, or charge unfair discriminatory rates for health insurance coverage for a person solely because of an intellectual or physical disability)

When an HMO knowingly makes any misleading representations, incomplete or fraudulent comparisons for the purpose of inducing any person to lapse, forfeit, terminate, surrender or convert any insurance policy or contract with another insurance company or HMO, they are in the unfair violation practice of?

Twisting ( Twisting is knowingly making misleading representations or incomplete or fraudulent comparisons for the purpose of inducing a person to termination existing coverage and purchasing new or different coverage that may or may not be in the persons best interest)

All of the following are basic types of health insurance plans EXCEPT A) Major medical B) Health maintenance organizations C) Basic medical expense D) workers compensation

Workers compensation (Workers compensation coverage is actually considered liability coverage because it pays those medical expenses of employees that an employer is legally liable to provide)

An HMO that is found to be in violation by committing an unfair trade practice as defined in the act, may suffer the penalty of? A) Suspension of certificate of authority B) Revocation of license C) Administrative fine D) any of the above

any of the above ( The penalty for the commission of unfair trade practice can range from probation to suspension or revocation of license of certificate of authority, and/or administrative fine up to $50,000)

Which of the following government health programs provides health insurance coverage to children who do not have access to adequate health care services?

Florida healthy kids ( Florida healthy kids provides health insurance coverage to children who do not have access to adequate health care services. Medicare is generally reserved for adults over the age of 65. Social security provides for workers- not children. Blue cross and blue shield is not a governmental health program)

All of the following are activities of living living EXCEPT? A) eating B) Transferring C) Speaking D) Dressing

Speaking ( The 6 activities of daily living recognized in LTC policies are eating, toileting, transferring, bathing, dressing and continence)

Medicare supplement policies, by law, must provide a free look provision of

30 days (Florida follows the NAIC model in following a 30-day free look provision)

The insurance company must retain all advertisements from the date the advertisement was first used, for how long?

3 years

What is the statute of limitations on lawsuits for health insurance policies

5 years ( No legal action may be brought on a health insurance policy within 60 days after written loss has been given. After 60 days in the state of Florida, legal action may be brought against the insurer for up to 5 years after filling proof of loss)

The Florida Employee Health Care Access Act serves which of the following purposes? A) It encourages limited group health insurance provisions provided by HMOs B) It requires employers to purchase insurance that covers all pre-existing conditions of covered employees without limitation C) It mandates minimal health insurance provisions to employees of companies with 10 or fewer employees D) It regulates group health insurance provisions provided by insurers or HMOs to small employers

It regulates group health insurance provisions provided by insurers or HMOs to small employers ( The Florida Employee Healthcare Access Act regulates group health insurance provisions provided by insurers or HMOs to small employers)

What is a MET?

Multiple employer trust is a group of 10 or more employers who form a trust in order to maximize tax implications of providing certain types of benefits for their employees, particularly life insurance)