ExamFX Colorado Health Insurance
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 a $100 per day. How much will the insurance company pay?
$120 day
What is the max $ that must be provided for annual prostate cancer screening?
$65
Payment of Claims Provision
(required) defines how proceeds are to be paid out + requirements to initiate death benefit claim
Grace Period
- 7 Days for Weekly Premium - 10 Days for Premium Policies - 31 Days for Other
LTC Coverage
- Individual LTC Policy - Group LTC Policy - LTC Rider - Must be for at least 12 Consecutive months Eligibility: - inability to perform 2 or more activities of daily living (bathing, dressing, continence, eating)
Preventative Care
- helps reduce cost of health care - early deduction - annual physicals, mammograms, immunizations
Insuring Clause
- parties to the contract - length of coverage - premium - types of loss covered Insurer + Insurer = Agreement
Required Provisions
1. Entire Contract 2. Time Limit of Certain Defenses 3. Grace Period 4. Renewal 5. Reinstatement 6. Notice of Claim 7. Claim Forms 8. Proof of Loss 9. Time of Payment Claims
In all health care plans under the ACA how many essential benefit categories are there?
10
Free-Look Period
10 days to review, make changes, or cancel policy.
Medicare part b
20 % of covered charges above the deductible
The Division of Insurance has requested information regarding an insurer's underwriting policies via e-mail. How many days does the insurer have to respond to this request?
20 days
Notice of Claims
20 days for the insured to report or notify insurer of a loss (insured)
Medicare Part B Patient Pay
20% of Covered Charges
In Colorado, long-term care insurance policies must pay for benefits if an insured cannot perform at least how many daily living activities?
3
In all individual and small employer health benefit plans how long is the grace period for a persons receiving the federal advance payment tax credit?
3 months
Medicare free-look period
30 days
Social Security Waiting Period
5 months
Proof of Loss
90 Days to send in proof of loss (insured)
Medicaid
A federal and state assistance program that pays for health care services for people who cannot afford them.
Consideration Clause
A part of the insurance contract that states that both parties must give something of value for the transfer of risk, and specifies the conditions of the exchange.
The premium charged for exercising the Guaranteed Insurability Rider is based upon the insured's
Attained age
LTC Benefit Period
Benefit periods are usually 2 to 5 years in duration, with "inside limits" on daily benefit amounts
What of the following includes information regarding a person's credit, character, reputation, and habits?
Consumer Report
COLA
Cost of living adjustments; the increase in a transfer payment or wage that reflects the increase in the price level
Guaranteed Renewable Allows:
Coverage is guaranteed, but rates can be adjusted for the entire class
Which type of insurance provides funds for a business to purchase the business interest of a disables partner?
Disability Buy-Sell
This arrangement specifies who will purchase a disables partner's interest in the event he or she becomes disabled
Disability buyout
Long term care coverage may be available as any of the following except..
Endorsement to a health policy
Consumer Driven Plans
FSA: all employees are eligible except self employed no statutory limits - limits are set by employer doesn't have to be covered by a health plan use it or lose it - money you put aside won't carry over HRA: all employees covered doesn't have to be covered by a health plan employee contributions no limits funds CAN carry over HSA: individual covered by an HDHP must be covered by HDHP individual or employer contribution annually specified limit funds CAN carry over
The benefits available to newborn children must include coverage for injury or sickness, and all medically necessary care and treatment for how many days?
First 31 days
To be eligible for a Health Savings Account, an individual must be covered by a
High Deductible health plan
What are the three basic medical expense insurance coverages?
Hospital, surgical, medical
In order for an insured under Medicare Part A to receive benefits for care in skilled nursing, which condition must be met?
Hospitalized for 3 consecutive days
Carry Over Provision
If the insured did not incur enough expenses during the year to meet the deductible, any expenses incurred during the last 3 months may be carried over to the next policy year to satisfy the new annual deductible
Which of the following riders would NOT increase the premium for a policyonwer?
Impairment rider
Taxation of Health Insurance
Individual Health Insurance Disability Income: Premiums = Not Deductible Benefits = Received income tax free Medical Expense: unreimbursed med expenses - deductible if itemized benefits = received income tax free Long Term Care: Premiums = may be deductible up to limits Benefits = received income tax free Excess of benefits = taxed as ordinary income
Underwriting a group health insurance plan that is paid for by the employer requires all of the following EXCEPT
Individual members of the group may select the level of benefits for their own coverage
The MIB was created to protect
Insurance companies from adverse selection by high risk persons.
Which of the following entities has the authority to make changes to an insurance policy?
Insurer's executive order
Which of the following is not a purpose of the long-term care act?
Make LTC affordable
Under ACA Which classification applies to health plans based on amount of covered costs
Metal level classification
Renewability
Noncancellable: no cancellation, no increase, for the life of the contract (usually 65) THE BEST
Medicare Eligibility
Over 65, or Permanently disabled, or ESRD, receiving social security disability for 2 years
Don has both a basic expense and a major medical policy. He is injured in an accident, which requires several major surgeries. This quickly exhausts Don's basic expense policy. What must Don do before his major medical policy can pick up where the basic expense policy left off?
Pay a special deductible on his major medical policy
Pending Claim
Phrase used when a claim is held back from payment - can be examined as often as reasonably required
Major Medical Insurance
Policies that provide high limits for catastrophic coverage and broad coverage for medical expenses. Major medical plans have deductibles, coinsurance, eligible expenses and a maximum dollar benefit.
Regarding the taxation of Business Overhead policies...
Premiums are deductible and benefits are taxed
Medicare Part D Provides
Prescription drug benefit
Claim Form
Promptly send to insured within a specific number of days - usually 15 days (insurer)
A lender is requiring that a borrower purchases an insurance policy through a particular insurer, as a condition of extension of credit,
Rebating
Disability Income Insurance
Replaces lost income in the event of disability Benefits are a percentage of the past income Exclusions apply
Which of the following scenarios would be an example of coercion on the part of the lender?
Requiring the debtor to acquire a policy from a specific producer
An insured wants to name her husband as the beneficiary of her health policy. She also wishes to retain all of the rights of ownership. The insured should have her husband named as what type of beneficiary?
Revocable
A producer who is licensed to transact several types of insurance wants to remove a line of authority from his license. What should the producer do?
Sbmit an appropriate form to the Commissioner and return the lisence for amendment
LTC Levels of Care
Skilled Care: medical personnel Intermediate Care: occasional nursing or rehab by professional Custodial Care: nonmedical, home setting Home Health Care: skilled nurse in the homes Adult Day Care: community center Respite Care: relief for family caregiver
Which of the following would basic medical coverage NOT ncover
Surgeon's services
Usual, Customary, and Reasonable
Terms that refer to the amount typically charged by health care providers for similar services in the area you live in. (Example: Your dermatologist charges $200 for an office visit, but most other dermatologists in your area charge $150. Your insurance company may reimburse based on a charge of $150.)
In comparison to consumer reports, which of the following describes a unique characteristic of investigative consumer reports?
The customer's associates, friends, and neighbors provide the data
Who is responsible for covering the expenses associated with the examination of domestic insurers
The examined insurer
Which of the following is NOT a feature of guaranteed renewable provision?
The insurer can increase the policy premium on an individual basis -
Time Payment of Claims
Typically 60 Days (insurer)
According to the rights of renewability rider for cancellable policies, all of the following are correct about the cancellation of an individual insurance policy EXCEPT
Unearned premiums are retained by the insurance compnay
HMOs (Health Maintenance Org)
a network of providers for which costs are covered inside but not outside the network - main focus is preventative care Health Maintenance Act of 1973 gatekeeper helps control the cots of healthcare by only making necessary referrals "Subscribers" = HMO
Which of the following persons is required to hold a producer license?
a person who negotiates insurance contracts
Which of the following is NOt covered under a long-term care policy?
acute care in a hospital
COBRA
allows a former employee that's covered by group insurance to stay in the plans - must apply within 60 days of termination - coverage extends for up to 18 months - 36 for dependents after employee's death or divorce - employee pays 102% of premium
Nonrenewable
cancellation at any time, increases - base on policy, no renewals WORST
An insurer neglects to pay a legitimate claim that is covered under the terms of the policy. Which of the following insurance principles has the insurer violated?
consideration
PPO's (Preferred Provider Org)
contracts with a group of independent hospitals and physicians within a certain area greater selection of providers - paid on a fee-for-service basis member may use providers in or out-of-network in exchange for a higher premium no PCP referrals
Entire Contract
copy of application + policy
All of the following are true about group disability income insurance EXCEPT
coverage applies both on and off the job
Coverage timeframe
coverage for accidents is immediate - but coverage for sickness may have a waiting period of 10 days
Basic Medical Insurance
covers hospitalization (room & board) and outpatient treatment no deductible / first dollar coverage
A health insurance policy that pays a lump sum if the insured suffers a heart attack or stroke is known as
critical illness
Insuring Clause States:
defines agreement and identities of the insured and the insurance company
PCP = Gatekeeper
describes doctor you go to for everything first - then refers you - primary care physician regularly compensated for the care of HMO subscribers (whether care is provided or not)
Cost Containment
designed to control the behavior of the plan participants - get looked at before jumping right to a specialist - controlled access of providers - large claim management - preventative care - second opinions
Capitation
fixed monthly amount paid per member of an HMO
Medicare Party B
funded by monthly premiums and from general revenues of federal government
Group Health Insurance Basics
group is formed for reason other than insurance master policy insureds receive certificates of insurance group underwriting
In LTC policies, as the benefit period lengthens, the premium
increases
Enrollment Periods for Medicare Part A
initial general special
Overinsurance
insurance that exceeds in amount the actual value of the person or property insured or insurance in a greater amount than the insured can afford
Which of the following statements concerning Medicare Part B is correct?
it pays for physician services, diagnostic tests, and PT
The provision that prevents the insured from bringing any legal action against the company for at least 60 days after proof of loss is known as
legal actions
On its advertisement, company claims funds are not available for payment.. guilty of
misrepresentation
Guaranteed Renewable
no cancellation, increases on renewal date, for the life of the contract (usually 65)
Time Limit of Certain Defenses
o Similar to incontestability clause in life insurance policies • Except that a fraudulent statement on a health application can be contested at any time unless the policy is guaranteed renewable, which usually last 2 years
Coordination of Benefits
only found in group health plans purpose is to avoid duplication of benefits when an insured is covered under multiple plans
Medicare Supplement Policies
or medigap are issued by private insurance , designed to fill the gaps in medicare. 30 day free-look, guaranteed renewable, under obra, may not discriminate. open enrollment is up to 6 months where first sign up for part b
If an accident happens during the grace period, the insurance company will...
pay the claim
Group Health Insurance Underwriting
purpose = not insurance size = maintain participation level turnover = flow of new members nondiscrimination = same coverage for all premium determination = age & gender & occupation
Exclusions
self-inflicted injures routine dental military
Service Area
the geographic area served by an insurance carrier
Medicare SELECT
type of Medigap policy available in some states where beneficiaries choose from a standardized Medigap plan.
In forming an insurance contract, when does acceptance usually occur?
when an insurer's underwriter approves coverage
prinicple of indemnity
you can't make more than your coverage