life and health

How many members to qualify for group insurance?

100 members And it is a ration of men and women, and average age

HIPAA applies to groups of

2 or more

Under a nonscheduled plan, what portion of the balance could an insured expect to pay for basic services

20%

An insured has a major medical policy with a 500 deductible and 80/20 coinsurance. The insured is hospitalized and sustains a 2500 bill. What is the maximum amount that the insured will pay

2500-500 (subtracting the deductible from overall total=2000 2000*.2 (80/20 rule, the 20%)=400 400+500 (orginial deductible+ the percentage)=900

How long must an insurer retain an advertisement for its long term care policies

3 years

What is the period of coverage for events such as death or divorce under COBRA

36 months

The inflation protection feature in long term care policies issued in this state must provide protectin for inflation at what percent annually

5%

How long is an open enrollment period for medicare supplement policies

6 months

A 63 year old man is planning to be employed until age 68. When will he be eligible for medicare

65, regardless of employment status

A hospital indemnity policy will pay

A benefit for each day the insured is in a hospital

Which of the following individuals is eligible for a health savings account

A person insured under a high deductible health plan HDHP

What is material misrepresentation

A statement by the applicant that upon discovery would affect the underwriting decision of the insurance company

Insurance policies are not drawn up through negotiations and an insured has little to say about its provisions. What contract characteristic does this describe

Adhesion

Which of the following is NOT a characteristic of preventative care in a HIC

Admitting members into the hospital

What documentation grants express authority to an agent

Agents contract with the principal

Under HIPAA, which of the following is incorrect regarding eligibility requirements for conversion to an individual policy

An individual who was previously coved by group health insurance for 6 months is eligible

A formulary must include how manu drugs in each treatment category

At least 2

Occasional visits by which of the following medical professional willl not be covered under LTCs home health care

Attending physcians

A man is still employed at age 65 and is now eligible for medicare. He wants to know what health insurance coverage he is eligible to receive. Which of the following options are available to him

Both group health and medicare

Which of the following options best depicts how the eligibility of members for group health insurance is determined

By conditions of employment

When an insurer offers services like preadmission testing, second opinions regarding surgery, and preventative care, which term would best apply

Case management provision

In order to provide services in ohio, a health insuring corporation must first obtain which of the following from the director

Certificate of authority

A health insurance plan that covers all accidents and sicknesses that are not specifically excluded from policy is referred to as

Comprehensive plan

What type of health insurance plans cover all accidents and sicknesses that are not speficially excluded in the policy

Comprehensive plans

Which of the following is not a characteristic or a service of an HMO plan

Contracting with insurance companies

What are the tax implications for contributions to a health savings account by the individual insured

Contributions are tax deductible

If the insureds share the cost of health insurance premiums with the employer, this would be known as what type of group health plan

Contributory

The purpose of managed care health insurance plans is to

Control health insurance claim expenses

5 basic characteristics of managed care plans

Controlled access to providers, comprehensive case management, preventative care, risk sharing, high quality care

What is the purpose of the gatekeeper in an HIC

Controlling costs

Difference between coinsurance and copay

Copay is a set dollar amount and coinsurance is a percentage of the expenses

Which of the following is the term for the specific dollar amount that must be paid by an HIC member for a service

Copayment

Orthodontics

Correction in dental, like braces

Which of the following is not true of basic medical expense plans

Coverage for catastrphic medical expenses

A health insurance policy that pays a lump sum if the insured suffers a heart attack or stroke is known as

Critical illness

Prior to issuance of a long term care policy to an applicant age 80 or older, the insurer must obtain all the following except

Date of previous doctor visit

The HMO act of 1973 required employers to offer an HMO plan as an alternative to regular health plans if the company had more than 25 employees. How has this plan changed since

Employers are no longer forced to offer HMO plans

What benefits are provided by medicare part c

Expanded benefits for a fee through private insurance programs such as HMOs and PPOs

Which of the following are the authorities tha an agent can hold

Express and implied

How many pints of blood will be paid for by medicare supplement core benefits

First 3

Which of the following is another name for a primary care physician in an HIC

Gatekeeper

Which of the following best describes how eligibility for a health insuring corporation HIC is determined

Geographic boundaries

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

Guaranteed

Under the privacy for HIPAA, protect information includes all individually identifiable health information

Held or transmitted in any form

Which of the following cases would a credit disability policy be issued

If an individual is in debt to a specific creditor, payment will be made for them until the return to work

Which type of s hospital policy pays a fixed amount each day that the insured is in a hospital

Indemnity

In which of the following locations would skilled care most likely be provided

Institutional setting

An insured is covered under a group health insurance plan. When the insured has her first child, who should she notify in order to have coverage for the newborn

Insurer, Within 31 days

Type of dental plan which is incorporated into a major medical expense plan is a

Integrated dental plan

What is the benefit of experience rating

It allows employers with low claims experience to get lower premiums

Which of the following is not true regarding flexible spending account

It does not have limits on contributions

Which of the following is true regarding risk retention group

It is a liability insurance company owned by its members

Which of the following is incorrect concerning medicaid

It is solely a federally administered program

Which of the following is true of a PPO

Its goal is to channel patients to providers that discount services

In franchise insurance, premiums are usually

Lower than individual policies, but higher than group policies

Every insurer marketing long term care insurance must establish marketing procedures to ensure all of the following except

Ltc policies are marketing effectively to prespective insureds

All of the following statements describe a MEWA except

MEWAs are groups of at least 3 employers

In group insurance, what is the name of the policy

Master policy

All the following statements concerning medicaid are correct except

Medicaid is a state funded program that provided health care to persons over 65 only That is medicare not medicaid

HIC benefits are paid in which of the following methods

Medical services

Which type of medicare policy requires insureds to use specific healthcare providers and hospitals (network providers) except in emergency situations

Medicare select

An insured does not have to pay coinsurance or deductibles on a full sereis mouth x-ray, but does have to pay a deductible to get his cavities filled. Which dental plan does he have

Nonscheduled Diagnostic and preventative services are generally not subject to coinsurance or deductibles in nonscheduled plans, but basic and major services are

When is the annual open enrollment for state insurance exchanges

November 1 through January 31

An insureds health claim internal appeal was denied. The insurer must do all of the following except

Off a payment plan

Insurers negotiate contracts with health care providers to allow subscribers access to health care services at a favorable cost

PPO

What medicare part helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care and hospice care

Part a

In which medicare supplement policies are the core benefits found

Part a-n (all plans)

What medicare part will cover lab services or diagnostic tests

Part b

What is another name for medicare advantage plans

Part c

According to the PPACA metal levels classification, if a health plan is expected to cover 90% of the cost for an average population, and the participants would coverage the remaining 10%, what type of plan is that

Platinum bronze-60/40 silver-70/30 gold-80/20 platinum-90/10

Who issues medigap policies

Private insurers

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

Prospective review

Which services are associated with the standard and poors and AM best

Rating the financial strength of insurance companies

Which of the following is not provided by an HIC

Reimbursement

When an employee is still employed upon reaching age 65 and eligible for medicare, which of the following is the employees option

Remain on the group health insurance plan and defer eligibility for medicare until retirement

Prosthodontics

Replacement of missing teeth with artificial, like dentures, bridgework

Endodontics dental treatment

Root canals, treatment of dental pulp

All of the following refer to specialty health care servcies except

Services that are provided in combination with other health care services

The ohio public employees retirement system replaced which of the following

Social security

Which of the following documents contain all information necessary to enable a consumer to make informed choices as to whether or not to enroll in the health insuring corporation

Solicitation document

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

Subscribers

Restorative dental treatment

Such as fillings or crowns

All of the following coverages are usually included under a dental insurance plan except

Teeth whitening

An applicants resources an assets may be used when determining eligibility for a low income subsidy under medicare part d as long as

The assets can be readily converted into cash within 20 days

What happens if a non-member physician is utilized under hte point of service plan

The attending physician will be paid a fee for service but the member patient will have to pay higher coinsurance amount

Which of the following is a charcteristic of a reicpocal insurance exchange

The cheif adminstrator of the insurer is called an attorney in fact

What is a birthday rule in coordination of benefits provision

The coverage of the parent whose birthday is earlier in the year is considered primary

An insured with medicare part d has reached the initial benefit limit and must now pay a portion of prescription drug costs. What is the term for this gap in coverage

The donut hole

How do employer contributions to a health savings account affect the insureds taxes

The employer contributions are not included in the individuals insureds taxable income

If an individual enrolls in medicare advantage plan on his 65th birthday when would coverage begin

The first day of the following month

Who chooses a primary care physician in an HIC

The individual member

How does a member of an HIC see a specialist

The primary care physician refers the member

If a group health policy covers individuals that reside in more than one state, which state has jurisdiction over the group policy

The state in which the policy was delivered

Which of the following is an example of a producers fiduciary duty

The trust that a client places in the producer in regard to handling premiums

What is the purpose of managed care health insurance plans

To control health insurance claims expenses

What is the purpose of the coinsurance provision in health insurance policies

To prevent overutilizaiton of the policies benefits

Which of the following is NOT the purpose of HIPAA

To provide immediate coverage to new employee who had been previously covered for 18 months

Periodontics

Treatment of surround and supporting tissue of teeth, gum disease

Can an insured who belongs to a pos plan use an out of network physician

Yes, but the copays and deductibles may be higher

What settlement options area available in life insurance policies

lumpsum/cash, fixed period and amount, life income, interest only