PA Accident and Health Insurance

All of these are considered sources of information that can assist an underwriter in determining whether or not to accept a risk EXCEPT

National Association of Insurance Underwriters

what is the purpose of the PA Life and Health Insurance Guaranty Association ?

Provide policy owner protection if an insurer becomes insolvent

Premiums paid that exceed 7 1/2% of an insured's Adjusted Gross Income (AGI) are tax-deductible when paid for which of the following plans?

qualified long term care plan

the role of the federal government was expanded when Medicaid was established by allowing by allowing the State to

receive matching funds to expand public assitance programs

The purpose of the Coordination of Benefits provision in group accident and health plans is to

avoid over-payment of claims

Why are dividends from a mutual insurer not subject to taxation?

because dividends are considered to be a return of premium

which situation would qualify an individual for receiving benefits from a qualified long term care policy?

becoming cognitively impaired (mentally ill)

a disability income policy can prevent an insured from earning a higher income than they were working by utilizing

benefit limits

a disability policy owner is injured and becomes totally disabled. The benefits pay for 2 years starting from the date of the injury. What is this time period called?

benefit period

an insured has a health plan that pays an established amounts in accordance with a list of injuries, surgical procedures, or other losses. this list is called

benefit schedules

Ted has a health insurance plan that requires him to pay a specific sum out of pocket before any benefits are paid in a calendar year. Which of these does his health plan have?

calendar year deductible

What is issued to each employee of an employer health plan?

certificate

all of the following are included as part of a contact in the entire contract provision EXCEPT

changes made by the producer

all of the following are elements of an insurance policy EXCEPT

claim forms

in which of the following processes will the insurer oversee the insured's hospital stay to confirm everything is going accordingly to schedule and that the insured will be released as planned?

concurrent review

in an insurance contract the element that shows each party is giving something of value is called

consideration

in order for a contact to be valid, it must

contain an offer and acceptance

_____ is NOT an element of a valid contract

countersignature

which of the following is not true regarding a critical illness plan

coverage is limited to a single devastating disease

Jennifer is required to pay a specific sum out of pocket before any benefits are paid in a year. Her health policy most likely contains a(n)

deductible

Medicare Part B covers

doctor's charges

What type of policy would only provide coverage for specific types of illnesses (cancer, stroke, etc)?

dread disease insurance

a medicare supplement policy must NOT contain benefits which

duplicate medicare benefits

all of these are characteristics of a major medical expense policy EXCEPT

elimination periods

Which prohibited act involves a producer spending a client's insurance premiums for his/her own personal use?

embezzlement

when soliciting insurance, a producer CANNOT

emphasize Guaranty Association benefits

Under group health insurance, a certificate of coverage is issued to the

employee

all of the following are qualifications for establishing a health savings account (HSA) EXCEPT

enrolled in a health plan with a prescription drug benefit

a field underwriter's main task is to

ensure an applicant's medical info is accurate and complete

the waiting period for a disability insurance policy

excludes payments for a short term illness and injury

which of the following is required to maintain a producer's licensee in Pennsylvania

field underwriter, who solicits insurance and earns commission

Violations of US Code Title 18 section 1033, may result in

fine and/or imprisonment

which of the following is NOT included in comprehensive major medical plans?

first-dollar coverage

a medicare supplement plan can be cancelled by the insurer

for non payment of premiums

a group disability income plan that pays tax-free benefits to covered employees is considered

fully contributory

a health insurance policy that allows an insurer to change the policy owner's premium

guaranteed renewable policy

the commissioner has the right and duty to

audit insurer financial reports and conduct market studies

In Pennsylvania, a Specified disease accident and health plan must provide a minimum benefit in the amount of

$5,000

Every Pennsylvania insurer, upon receiving notification of a claim, must acknowledge receipt of the notice within

10 days

How many employees must an employer have for a terminated employee to be eligible for COBRA

20

a licensed producer must report any administrative action taken against the licensee in another jurisdiction or by another agency department in PA within how many days of the final disposition?

30 days

in a long term care policy the right to examine period is

30 days

within how many days must the producer report to the commissioner any changes made against him/her?

30 days

As of January 1, 2014, an employer with up to 25 full time equivalent (FTE's) with average annual wages of less than $50,000 may be eligible for a tax credit of ___ of the premiums paid by the employer.

50%

No Long-Term Care policy may exclude pre-existing conditions for a period of more than

6 months

in Pennsylvania, an employee must request spousal coverage under a group sponsored accident and health plan within __________ days of marriage

60 days

In an employer-sponsored contributory group Disability Income plan, the employer pays 60% of the premium and each employee pays 40% of the premium. Any income benefits paid are taxed to the employee at

60% of the benefit

Which of the following is INELIGIBLE to participate in a Section 125 Plan?

An S-Corp Owner with a greater than 2% share

how is medicare part b (supplementary medical insurance) funded

General tax revenue and user premiums

Which type of coverage pays an amount per day for hospitalization directly to the insured regardless of the insured's other health insurance?

Hospital Indemnity

an employer is issued a group medical insurance policy. This single contract is known as

Master Policy

what is the contract called that is issued to an employer for a Group Medical insurance plan?

Master policy

Mark continues working after the age of 65 and is covered through his employer's group health plan. Which of the following statements is TRUE?

Medicare is the secondary payer

This MANDATORY health policy provision states that the policy, including endorsements and attached papers, constitutes

The entire insurance contract between the parties

which of the following nursing home options would BEST suit an individual who needs care and supervision but NOT full-time care?

assisted living facilities

HIPPA considers which of the following as "individually identifiable health information?

a person's health claim information

A plan in which an employer pays insurance benefits from a fund derived from the employer's current revenues is called

a self funded plan

after the passage of the medigap law in 1990 what was developed by the NAIC?

a standardized model Medicare Supplement Policy

Under a disability income policy, which provision would be payable if the cause of an injury is unexpected and accidental?

accidental bodily injury provision

holding premium funds for timely submission to the insurer is an example of

acting in a fiduciary capacity

Group dental plans will frequently place a limit on annual benefits in order to minimize

adverse selection

people with higher loss exposure have the tendency to purchase insurance more often than those of average risk. this is called

adverse selection

which of the following do coordination of benefits allow

allows the secondary payer to reduce their benefit payments so no more than 100% of the claim is paid

loss of income insurance provides

an individual the means to replace wages

a licensee may only sell, solicit, and negotiate insurance contracts on behalf of the

appropriating insurer

the difference between a long term care partnership and a non-partnership plan is which of the following?

asset protection

Bill requires some nursing care and supervision but NOT full-time care. Which of these nursing home options would best serve him?

assisted living

Credit Accident and Health plans are designed to

help pay off existing loans during periods of disability

which of the following is NOT included under a health benefit plan

hospital indemnity plan

sharing 50% of producer's commission with the insured is an example of

illegal inducement

which of the following actions may an insurance company NOT do in a health policy that contains a guaranteed renewable premium benefit ?

increase premiums on an individual basis

When a producer offers something of value in return for the purchase of an insurance policy, which prohibited sales practice has been committed?

inducement

Health insurance will typically cover which of the following perils?

injury due to accident

which of the following is present when an applicant stands to lose value if the insured dies?

insurable interest

who is responsible for assembling the policy forms or insureds?

insurance carriers

an accident and health policy that provides reimbursement benefits makes them payable to the

insured

An applicant's character and personal habits can be obtained for underwriting purposes from which source?

investigators consumer report

which of the following statements regarding Group Disability income insurance is true?

it provides benefits for nonoccupational illnesses and injuries

Without a Section 125 Plan in place, what would happen to an employee's payroll contribution to an HSA?

it would be considered taxable income to the employee

a common exclusion with Vision Plan is

lasik surgery

which contract is insurable interest a component of?

legal purpose

Someone needing custodial care at home would require which type of coverage?

long term care

The election of COBRA for continuation of health coverage will

maintain the same coverage and increase premium

which of the following is considered to be a point of service (POS) plan?

managed care plan

In contrast to a guaranteed renewable policy, a noncancellable policy

may never raise premiums

the focus of major medical insurance is providing coverage for

medical and hospitalization expenses

which of these is likely to occur when life or health insurance is being applied for

medical history from the insured may be reviewed and reported

which of these gaps in medicare coverage is addressed with medicare supplemental insurance ?

medicare in-hospital deductible

what is the required action to be taken by Pennsylvania licensee before operating under an assumed business name?

notify commissioner

Paul is an employee who caught a disease unique to the trade in which he was exposed to. Paul has a(n)

occupational disease

what makes an insurance policy a unilateral contract

only the insurer is legally bound

Richard owns an insurance policy that is renewable only at the option of the insurance company. His policy is considered to be

optionally renewable

the document that describes policy features, benefits, exclusions, and riders in a long term care policy is known as the

outline of coverage

Which clause defines total disability as being unable to perform the major duties of the insured's regular occupation?

own occupation clause

what kind of life insurance policy issued by a mutual insurer provides a return of divisible surplus?

participating life insurance policy

states that have "no loss no gain" laws require a replacing policy

pay for ongoing claims under the policy it replaces

which of the following would evidence ownership in a participating health insurance contract?

policy ownership

An insured applicant with a below average likelihood of loss is typically considered to be a

preferred risk

a rehabilitation benefit is intended to

prepare the insured to return to employment

a health insurance policy will typically cover

preventative health services

which of the following provides Medicare supplement policies?

private insurance companies

who can receive an insurance commission?

producer

what is required before an insurance producer can act as a representative of an insurer?

producer needs to be appointed by that insurer

when comparing an HMO to a PPO, the PPO

provides a greater choice of providers

according to the affordable care act, what metal tier is required to have an actuarial value of 70% with covered individuals paying 30% through deductibles, co-pays, and other cost sharing features?

silver plan

generally speaking, which three levels of care are Long-Term Care policies provided with

skilled nursing, intermediate, and custodial care

which of the following is NOT a type of Medicare Advantage Plan

socical security disability income

in an insurance contract,the applicant's "consideration" is the

statements made in the application and the premium

An insurer's claim settlement practices are regulated by the

states insurance departments

distributions from a Health Savings Account (HSA) for qualified medical expenses are

tax-free

which of the following decisions would a Health Savings Account (HSA) owner not be able to make

the amount contributed by the employer

when a preferred provider organization (PPO) insured goes out of network which of the following actions occur?

the insurer will pay a reduced amount

under the affordable care act, a large employer that does NOT provide health insurance owes an employer mandate penalty MUST pay an annual penalty, which is calculated by multiplying $2,000 by

the number of full times employees minus 30

under a contract of adhesion

the terms must be accepted OR rejected in full

Legal purpose is a term used in contract law meaning

there must be legal reasons for entering into the contract

which of the following is the purpose of medical cost management ?

to control health claim expenses

Insurance represents the process of risk

transference

when an insurance company consistently fails to provide reasonable explanations for the denial of a claim, this is called an..

unfair claim settlement

at what point does a self-insured group qualify for stop-loss coverage?

when claims exceed a specified limit in a set period of time

How is a health provider reimbursed if they do NOT have an agreement in place with the insurance company?

with a usual, customary, and reasonable fee

Pennsylvania law requires that an insurer must notify the Commissioner of a producer appointment termination

within 30 days of termination