MO guarantee exam

which of the following best describes the type of care provided by HMOs? -preventive -elective -major medical -fee-for-service

preventive

an employee is insured by a group major medical plan that is provided through her employer. the employer contributes 75% of the premium and the amployee contributes the remaining 25%. if the insured received a benefit from this policy in the amount of $1,000, how much of this benefit would be taxed as income?

$0

elaine's basic medical expense policy has a $500 per day limit for room and board in a hospital for a maximum of 5 days. Elaine got sick and had to spend 3 days in the hospital at $650 a day. how much will Elaine have to pay to cover the rest of her room and board charges?

$450

all of the following are true regarding key person disability income insurance EXCEPT: -the employer pays the premiums -premiums are tax deductible as a business expense -the employee is the insured -the employer receives the benefits if the key person is disabled

-premiums are tax deductible as a business expense

of the 16 credit hours required for continuing education, how many hours must be specific to ethics, state law and producers duties?

3 hours

when can an insured initiate legal action against the insurer

60 days after submitting proof of loss

the probationary period is

a specified period of time that a person joining a group has to wait before becoming eligible for coverage

all health insurance policies issued in this state must provide coverage for maternity services. how many hours of inpatient care must be provided to a mother after a vaginal delivery?

at least 48

which of the following would be an example of an insurer participating in the unfair trade practice of discrimination?

charging an insured higher premiums based on her race

policy delivery refers to the delivery of the

completed insurance policy to the policyowner

what is the purpose of a gatekeeper in an HMO?

controlling costs

what policy must provide coverage for child immunization from birth to age 5?

group health

all of the following are excluded from coverage in an indv health insurance policy EXCEPT: -treatment received in a government hospital -mental illness -experimental procedures -cosmetic surgery

mental illness

Medicare Part A services do not include which of the following? -post hospital skilled nursing facility -hospitalization -hospice care -private duty nursing

private duty nursing

an insured had a heart attack while jogging, but is expected to return to work in approximately 6 weeks. the insureds disability income policy will

replace a % of his lost income

what must be included in the notice of an insurers intention to nonrenew a health insurance policy

the reason for nonrenewal

what is the purpose of a benefit schedule?

to state what and how much is covered in the plan

what fee would a business entity be required to pay in order to obtain an insurance producers license?

$100

level 2 violations of unfair insurance trade practices may result in a monetary penalty of up to

$25,000

an insurer must notify the consumer in writing that an investigative consumer report has been requested, within how many days of the initial request?

3 days

what time period is the general enrollment period of Medicare Part B?

January 1st through March 31st each year

the uniform provision law that prevents an insurance company from altering its agreement with a policyholder by referring to documents or other items not contained in the policy is called the

entire contract provision

with respect to the entire contract clause in health policies, who has the authority to make changes to an existing policy?

only an executive officer of the company

under the payment of claims provision, to whom will the insureds benefits be paid in the insured is deceased?

the insureds primary beneficiary

which of the following services will NOT be provided by an HMO? -unlimited coverage for treatment of drug rehab -treatment of mental disorders -emergency care -inpatient hospital care outside the service area

-unlimited coverage for treatment of drug rehab

a policyholder with a dependent child who needs hospital and medical coverage past a limiting age due to physical or mental handicap must furnish which of the following for continued coverage?

-proof of incapacity for self sustaining employment and dependency upon the policyholder for support and maintenance

what is the purpose of the impairment rider in a health insurance policy

to exclude coverage for a specific impairment

all of the following are among the minimum maternity benefits required in health insurance policies in the state of MO, EXCEPT: -3 post discharge visits by a physician -48 hours of inpatient care after a vaginal delivery -96 hours of inpatient care after a c section -2 post discharge visits by a registered nurse

-3 post discharge visits by a physician

all of the following are mandatory provisions for group health insurance policies EXCEPT: -a provision excluding pre existing conditions -a provision explaining the conditions for policy termination -a provision stating that the insurer is required to issue a certificate of insurance -a provision explaining the time limit on certain defenses

-a provision excluding pre existing conditions

a husband and wife both incur expenses that are attributed to a single major medical insurance deductible. what type of deductible do they have in their policy?

family

an insured purchased a health insurance policy with a renewability clause that states the policy is "guaranteed renewable." this means that as long as the required premiums are paid, the policy will continue until the insured

reaches age 65

in regards to the field of insurance, fiduciary capacity is defined as

the responsibility of producers to handle funds entrusted to them by the insured

an employee has a flexible spending account (fsa) with a $5,000 annual benefit. this year the employee used $3,000. what would be the amount of the benefit available to the employee next year?

$5,000

HMO members pay a small fee when they see their primary care physician. this fee is called a

copay

to be valid, an insurance policy must have all of the following EXCEPT: -countersignature -acceptance -consideration -offer

countersignature

under individual and group health plans, coverage must be provided to the newborn child of the insured starting

from the moment of birth

ed is covered under a health plan provided by his employer. he was told that his insurance would pay the majority of the covered expenses if he would choose to see a provider in his plans list. if ed chose to be treated by a provider who was not on the list, his portion of the bill would be greater. ed is covered under a

preferred provider plan

in group insurance, the primary purpose of the Coordination of Benefit provision is to

prevent overinsurance

an insured has an illness that was diagnosed through video conferencing between the insureds doctor and a doctor in another city. this describes what type of medical practice?

telehealth

what is the maximum age that a disabled insured worker may receive social security disability benefits?

65

under the mandatory uniform provision "notice of claim", written notice of a claim must be submitted to the insurer within what time parameters

within 20 days

what is the maximum fine for willful violations of the Directors cease and desist order?

$100,000

proper premium handling is part of the producers fiduciary responsibility. within how many days must a producer remit the premiums collected for insurance policies?

30 days

insurance contracts are unilateral in nature. what does that mean

only one party makes a promise

the director may suspend, revoke, refuse to issue or renew a producers license if the producer

previously had their license revoked in another state

which of the following is NOT mandatory under the uniform provisions law as applied to accident and health policies? -physical examination and autopsy -entire contract -probationary period -time limit on certain defenses

probationary period

an insured was diagnosed 2 years ago with kidney cancer. she was treated with surgeries and chemo and is now is remission. she also has a 30 year smoking history. the insured is now healthy enough to work and has just started a full time job. what describes the health insurance that she will most likely receive

she would be covered under her employers group health insurance plan, without higher premiums

what does the application of contract of adhesion mean?

since the insured does not participate in preparing the contract, any ambiguities would be resolved in favor of the insured

a veteran of a foreign war is issued an individual long term care policy in March. in October, he is admitted to a nursing home for a liver condition first diagnosed 11 years ago. what would be true regarding the veterans policy coverage?

the care will be covered. the loss occurred after six months of coverage

under the mandatory uniform provision Legal Actions, an insured is prevented from bringing a suit against the insurer to recover on a health policy prior to

60 days after written proof of loss has been submitted

an employee that becomes ineligible for group coverage because of termination of employment or change in status, must exercise extension of benefits under COBRA within

60 days

when can an insured initiate legal action against the insurer?

60 days after submitting proof of loss

an insured was seriously injured in a skiing accident that required him to be hospitalized for 5 weeks. his medical expense policy covered all of the following EXCEPT

loss of income while hospitalized

if an insured is not entirely satisfied with a policy issued, the insured may return it to the insurance company and receive a refund of the entire premium paid, within what time?

within 10 days of when the policy was delivered

individual and group health policies in this state will cover which of the following procedures for women? -a biennial mammogram for all women -a mammogram for any woman with any family history of any type of cancer -a baseline mammogram for women age 30 -a baseline mammogram for women age 35-39

-a baseline mammogram for women age 35-39

which of the following is true regarding coverage for mammography in health insurance policies in this state? -coverage must be available only upon the recommendation of a physician - it is not mandatory coverage -insurers may charge higher copays than for other radiological exams -an annual mammogram for women over age 50 must be included

-an annual mammogram for women over age 50 must be included

for which of the following reasons could an insurer terminate a long term care insurance policy? -nonpayment of premium -the advanced age of the insured -deterioration in physical health of the insured -deterioration in mental health of insured

-nonpayment of premium

the director has the power and authority to perform all of the following EXCEPT: -amend regulations -write insurance statutes -regulate the internal affairs of the department of insurance -aid in the interpretation of any state insurance law

-write insurance statutes

if an insured submits a written proof of loss, what is the maximum amount of time after submittal that the insured has to initiate legal action

3 years

the corridor deductible applies between

basic and major medical coverage

an applicant misstates his age on his application for a health insurance policy. he states that he is 39, but his actual age is 49. when he files a claim, what will most likely happen?

benefits paid will be those that would have been purchased at the correct age

an agent delivers a life policy. he explains a policy change was made and asks the applicant to sign a statement acknowledging the changes were explained. the agent says the premium has not been paid and must be paid before the policy goes into effect. he collects a statement of good health, relinquishes the policy, and leaves. what did he do wrong?

he left the policy with the insured without collecting a premium

an insured has an individual disability income policy with a 30 day elimination period. he becomes disabled on June 1st for 15 days. when will he collect on his disability income payments

he wont collect anything

an insured's hospital policy states that it will pay him a flat fee of $75 per day for each day he is hospitalized. the policy pays benefits on what basis?

indemnity

all of the following must sign an application for health insurance EXCEPT: -the proposed insured -applicant -producer -insurer

insurer

riley reads an agreement on the first page of her policy which includes a list of losses that will be covered by her insurer. what is the name of this agreement

insuring clause

Agents may be found guilty of defamation if they make a false statement that is intended to?

maliciously criticize another insurance company

which of the following is NOT a required coverage in health insurance policies in MO? -chemical dependency -mental retardation -immunization -bone marrow transplants

mental retardation

guaranteeing future dividends is considered to be an unfair or deceptive act known as

misrepresentation

following a covered loss, the time payment of claims provision requires that an insurance company pay disability income benefits no less frequently than

monthly

Under the Affordable Care Act, when would pregnancy be considered a pre-existing condition?

never

an applicant for an insurance license has failed his written examination. Most likely, the fee for the examination will be

nonrefundable

what does basic medical expense cover?

nonsurgical services a physician provides

a licensee approved to teach a continuing education course may

receive continuing education credit the same as a person taking the course

an insured wants to cancel her health insurance policy. which portion of the contract would explain cancellation rights?

renewability provision

an applicant for a disability insurance policy has a heart condition of which they are unaware and therefore they answer no to the question pertaining to heart problems on their application. there answer is considered to be a

representation

what term relates to disability income insurance? -insurable interest -residual benefit -coinsurance stop loss -deductibles

residual benefit

to become the director of insurance, who must the individual be appointed by?

the governor with consent of the senate

a man is an attorney when he applies for a health policy. he decides to become a professional bungee jumper. he files a claim. what should happen?

the insurance company will pay the claim according to the benefits available if the correct premium had been paid

who must maintain control and responsibility over al dissemination of an insurers advertising

the insurer

the elimination period in a disability income policy is better known as

the period of time an insured must wait after the onset of an illness or injury before benefits begin

if an applicant submits the initial premium with an application, which action constitutes acceptance?

the underwriters approve the application

which of the following is true about retrospective commissions to insurers in this state? -they are prohibited -they are acceptable -they may vary with the loss experience -they are permitted as long as all the claims are paid

they are prohibited

which of the following is true regarding copayment and coinsurance for services provided by a physical therapist under a health benefit plan?

they must be the same as for the services of a primary care physician

what is the purpose of a disability buy-sell agreement

to allow the business buyout in case of the owners disability

under the long term care marketing regulations, which of the following questions would a producer NOT have to ask the applicant in order to determine if the purchase is suitable? -how much are you able to pay in premiums? -do you currently have any Medicare supplement policies? -are you planning to replace an existing health insurance? -what is the amount of your existing health or long term care insurance?

-how much are you able to pay in premiums?

if an insured submits a written proof of loss, what is the maximum amount of time after submittal that the insured has to initiate legal action?

3 years

a medicare supplement policy must have a free look period of at least

30 days

missouri law requires that producers notify the director of any change of address within

30 days

how is the MO insurance guaranty association funded

by member insurers

in addition to participation requirements, how does an insurer guard against adverse selection when underwriting group health?

by requiring that the insurance be incidental to the group

which of the following is NOT true regarding a noncancellable policy? -insurer can increase the premium above what is stated in the policy if claims experience is greater than expected -insurer cannot cancel the policy -the guarantee to renew coverage usually only applies until the insured reaches age 65 -insured has the unilateral right to renew the policy for the life of the contract, and may discontinue paying premiums to cancel it

-insurer can increase the premium above what is stated in the policy if claims experience is greater than expected

which of the following scenarios would require that an insured is provided with a conversion option from group to individual health insurance coverage? -the insureds employer was terminated -the insured failed to pay premium payments on time -the group policy was terminated -the insured had continuous coverage under the policy

-the insured had continuous coverage under the policy

if a nonresident producer wishes to sell insurance in the state of MO, the producer must meet all of the following requirements EXCEPT: -reside in a state which allows the same privileges to MO residents -submit an application for licensure to the Director -take and pass the MO insurance licensing exam -be licensed in another state in good standing

-take and pass the MO insurance licensing exam

if an insured is injured while committing an illegal act and his health policy contains the illegal occupation provision, what percentage of the claim will be paid

nothing

which statement best describes agreement as it relates to insurance contracts? -all parties must be capable of entering into a contract -each party must offer something of value -one party accepts the exact terms of the other party's offer -the intent of the contract must be legally acceptable to both parties

one party accepts the exact terms of the other party's offer

according tot he time limit on certain defenses provision, statements or misstatements made in the application at the time of issue cannot be used to deny a claim after the policy has been in force for a minimum of how many years

2 years

among people in the same class and life expectancy, which of the following factors can be used to influence premium rates? -occupation -ancestry -marital status -race

occupation

an insurer is attempting to determine the insurability of an applicant and decides to obtain medical information from several different sources. who must be notified of the investigation?

the applicant

once the initial benefit on Medicare part D is reached, how is the beneficiary affected?

the beneficiary is then responsible for a portion of prescription drug costs

which of the following scenarios would require that an insured is provided with a conversion option from group to individual LTC coverage? -the insured employer was terminated -the insured failed to pay premium payments on time -the group policy was terminated -the insured had continuous coverage under the policy

-the insured had continuous coverage under the policy

during policy solicitation, an insurer exaggerates the financial condition of one of its competitors, and makes it sound worse than it is. this is an example of an unfair trade practice of

defamation

when does coverage for a newborn begin, and within what period of time must the insurer be notified in order for the newborns coverage to be continued?

from the moment of birth, and the insurer must be notified within 31 days

the guaranteed purchase option is also referred to as the

future increase option

which of the following best describes a major medical expense policy? -it provides surgical coverage to an insured with a schedule indicating charges for each procedure -it provides coverage for in-hospital doctor visits that are of a nonsurgical nature -it provides coverage to an insured who is confined to a hospital with a daily benefit amount and a specified benefit period -it provides catastrophic medical coverage beyond basic benefits on a usual, customary, and reasonable basis

-it provides catastrophic medical coverage beyond basic benefits on a usual, customary, and reasonable basis

all life and health policies must provide a clear and conspicuous disclaimer regarding the insurance guaranty association on the face page of the policy. this disclaimer must do all of the following EXCEPT: -warn the policy holder that the guaranty association may not cover the policy -state the name and address of the life and health insurance guaranty association and insurance department -state that the insurer and its agents are protected by the guaranty association in case of insolvency -state that the insurer is prohibited by law from using the existence of the guaranty association for the purpose of solicitation or inducement of insurance

-state that the insurer and its agents are protected by the guaranty association in case of insolvency

medicare is a health insurance program for all of the following EXCEPT: -those with low income and low assets - those 65 or over -those with permanent kidney failure - those who have been on social security disability for 2 years

those with low income and low assets

how often must the Director conduct financial examinations of domestic insurers?

at least once every 5 years

regarding the consideration clause, which of the following is NOT correct? -consideration of the insurer and insured must be equal -consideration is defined as the exchange of values -the insurers consideration consists of providing coverage -the insureds consideration consists of providing information on the application, as well as agreeing to pay the premium

-consideration of the insurer and insured must be equal

a producer has been found guilty of 5 violations on unfair methods of competition and deceptive practices. what would be the amount of fine the producer will have to pay?

$5,000

which of the following statements is NOT true regarding health insurance policy provisions? -all indv policies contain universal mandatory provisions -insurers may only offer optional provisions that are allowed by the state where the policy is delivered -insurers may add provisions that are not in conflict with uniform standards -all additional provisions written by insurers are cataloged by their respective states

-all additional provisions written by insurers are cataloged by their respective states

which of the following is INCORRECT regarding the definition of total disability? -disability is defined differently under certain disability income policies -total disability can be the inability to perform any occupation for which a person is reasonably suited by reason of education, training, or experience -total disability can be the inability to perform the duties of ones own occupation -total disability is the inability to perform partial duties of any occupation for which a person is suited by reason of education, training, or experience

-total disability is the inability to perform partial duties of any occupation for which a person is suited by reason of education, training, or experience

under a group health insurance plan, benefits may be extended to all of the following dependents EXCEPT: -the spouse of the certificate holder - a 30 year old mentally handicapped son of the primary certificate holder - a dependent parent living with the primary certificate holder - a 27 year old married daughter who is attending college and lives with her parents

- a 27 year old married daughter who is attending college and lives with her parents

what is a formulary?

a list of prescription drugs covered by a prescription drug plan

an individual received a producers license in December of 2012. when must the license be renewed?

by December 2014

in health insurance, the length of the grace period varies according to the

mode of premium payment

which of the following is consideration on the part of an insurer? -decreasing premium amounts -paying the premium -underwriting -paying a claim

paying a claim

insureds have the right to do what if they have NOT received the proper claim forms within 15 days of their notice to the insurer of a covered loss under a major medical policy

submit the description in their own words on a plain sheet of paper

what is the allotted grace period for an insured who pays a $200 premium on a monthly basis?

10 days

within what time frame must a policyholder file a petition for adoption?

30 days of the birth or placement of the child

under the mandatory uniform provision proof of loss, the claimant must submit proof of loss within what time period after the loss?

90 days

under the mandatory uniform provision "notice of claim", written notice of a claim must be submitted to the insurer within what time parameters?

within 20 days