RI Health Insurance Exam

An insured's long-term care policy is scheduled to pay a fixed amount of coverage of $120 per day. The long-term care facility only charged $100 per day. How much will the insurance company pay?

$120 a day, regardless of actual cost

Any licensed person whose activities affect interstate commerce and who knowingly makes false material statements related to the business of insurance may be imprisoned for up to

10 years

According to OBRA, what is the minimum number of employees required to constitute a large group?

100

For how many days of skilled nursing facility care will Medicare pay benefits?

100 days

S is a sole business proprietor who owns a medical expense plan. What percentage of the cost of the plan may he deduct?

100%

How many excess continuing education credit hours may licensees carry over from one licensing period to the next?

12 hours

Producers who have allowed their license to lapse may reinstate the license without retaking the examination within what maximum time period?

12 months

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

15 employees

Which of the following disability income policies would have the highest premium?

15-day waiting period / 10-year benefit period

To be eligible under HIPAA regulations, for how long should an individual converting to an individual health plan have been covered under the previous group plan?

18 months

Insured health plans must provide mental health benefits on a nondiscriminatory basis for the diagnosis and treatment of biologically-based mental health disorders for children and adolescents under what age?

19 years old

COBRA applies to employers with at least

20 employees

Following an injury, a policyowner covered under Medicare Parts A & B was treated by her physician on an outpatient basis. How much of her doctor's bill will she be required to pay out-of-pocket?

20% of covered charges above the deductible

If a producer is found guilty of a violation which has caused a claimant to suffer actual economic damages, a court may award punitive damages in addition to the amount of the claim. This amount cannot exceed what percentage of the claim?

25% of the claim

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

30 days

One of the differences between group underwriting and individual underwriting is that there is little or no medical information required regarding plan participants in groups of

50 or more

The minimum number of credits required for partially insured status for Social Security disability benefits is

6 credits

Benefit periods for individual short-term disability policies will usually continue from

6 months to 2 years.

What is the continuing education requirement for producers during the initial licensing period of 36 months?

60 hours, including 3 hours in ethics

A carrier must maintain records of each grievance process for how many years?

7 years

Most policies will pay the accidental death benefits as long as the death is caused by the accident and occurs within

90 days

A deductible is

A specified dollar amount that the insured must pay first before the insurance company will pay the policy benefits.

Which of the following is another term for an authorized insurer?

Admitted

If an insurance company makes a statement that its policies are guaranteed by the existence of the Insurance Guaranty Association, that would be considered

An unfair trade practice

The premium charged for exercising the Guaranteed Insurability Rider is based upon the insured's

Attained age

The gatekeeper of an HMO helps

Control specialist costs.

Which of the following statements about occupational vs. nonoccupational coverage is TRUE?

Disability insurance can be written as occupational or nonoccupational.

An insured is hospitalized with a back injury. Upon checking his disability income policy, he learns that he will not be eligible for benefits for at least 30 days. This indicates that his policy is written with a 30-day

Elimination period

The authority granted to an agent through the agent's contract is referred to as

Express Authority

What are the 2 types of Flexible Spending Accounts?

Health Care Accounts and Dependent Care Accounts

Which of the following riders would NOT increase the premium for a policyowner?

Impairment rider

Which of the following factors about the insured determines the amount of disability benefit that the insured will receive?

Income

The Patient Protection and Affordable Care Act includes all of the following provisions EXCEPT

Individual tax deduction for premiums paid.

Which of the following is true regarding a risk retention group?

It is a liability insurance company owned by its members.

Concerning Medicare Part B, which statement is INCORRECT?

It is fully funded by Social Security taxes (FICA).

Which of the following is true of a PPO?

Its goal is to channel patients to providers that discount services.

Under what conditions may a small employer insurer deny coverage to certain individuals in the group?

Late enrollees

Which of the following is considered a presumptive disability under a disability income policy?

Loss of two limbs

All of the following are characteristics of a Major Medical Expense policy EXCEPT

Low maximum limits.

Which of the following best describes an HMO?

Medical organization providing care assume part of the patient's health care-related risk

Which of the following statements is correct?

Medicare will cover nursing home care if it is part of the treatment for a covered illness.

An applicant for a health insurance policy returns a completed application to her agent, along with a check for the first premium. She receives a conditional receipt two weeks later. Which of the following has the insurer done by this point?

Neither approved the application nor issued the policy

In long-term care insurance, what type of care is provided with intermediate care?

Occasional nursing or rehabilitative care (less frequent basis than skilled care.)

Which of the following is NOT among the goals of a Medicare supplement application?

Presuming the applicant is eligible for Medicaid, based on the nature of the policy

Under which provision can a physician submit claim information prior to providing treatment?

Prospective review

Which of the following insurance options would be considered a risk-sharing arrangement?

Reciprocal

Regarding cost containment in medical plans, what type of review process do employers and insurers use to evaluate the utilization review process and the effectiveness of the professionals involved in large insurance claims?

Retrospective review

Which of the following is NOT covered under Part B of a Medicare policy?

Routine dental care

Which of the following is a health care program funded by the federal government for the retirees and spouses of the military services?

TRICARE

What type of information is NOT included in a certificate of insurance?

The cost the company is paying for monthly premiums

In terms of deductibles, what is the relation between mental health coverage and "standard" illness coverage?

The deductibles are required to be the same.

Who chooses a primary care physician in an HMO?

The individual member

Which of the following is correct regarding selecting a primary care physician in a PPO plan?

The insured may choose medical providers not found on the preferred list.

Which of the following is NOT a feature of a guaranteed renewable provision?

The insurer can increase the policy premium on an individual basis.

An agent is in the process of replacing the insured's current health insurance policy with a new one. Which of the following would be a proper action?

The old policy should stay in force until the new policy is issued.

Which provision states that the insurance company must pay Medical Expense claims immediately?

Time of Payment Claims

Under the Physical Exam and Autopsy provision, how many times can an insurer have the insured examined, at its own expense, while a claim is pending?

Unlimited

Forcing a client to buy insurance from a particular lender as a condition of granting a loan is defined as

coercion

An insured is receiving hospice care. His insurer will pay for painkillers but not for an operation to reduce the size of a tumor. What term best fits this arrangement?

cost-containment

In disability income insurance, the own occupation definition of disability applies

for the first 2 years, or 24 months

Which of the following is the most common time for errors and omissions to occur on the part of an insurer?

policy delivery

Medicare Part D provides

prescription drug benefits

An underwriter may reject an application for health insurance if the rejection is based upon which of the following?

prescription usage

Todd has been informed that he has a hernia which requires repair. When Todd researches the cost, he learns that his insurance plan will cover 200 points worth of surgical expenses. Each point represents $10, which means that $2000 of his surgery will be covered by his insurance plan. What system is Todd's insurance company using?

relative value system

Events in which a person has both the chance of winning or losing are classified as

speculative risk

Which of the following are responsible for making premium payments in an HMO plan?

subscribers

An insured who has an Accidental Death and Dismemberment policy loses her left arm in an accident. What type of benefit will she most likely receive from this policy?

the capital amount in lump sum

Under a health insurance policy, benefits, other than death benefits, that have not otherwise been assigned, will be paid to

the insured

Under the Accidental Death and Dismemberment (AD&D) coverage, what type of benefit will be paid to the beneficiary in the event of the insured's accidental death?

the principle sum

Within how many days must a carrier send an insured a written acknowledgement of the receipt of the insured's grievance?

within 15 days