NJ Health Producer

A person is covered under the Temporary Disability Law for a given illness. The illness subsides but then relapses. What is the maximum number of days that can pass between the bouts of illness before the two illnesses are classified as having two different disability periods?

14

What is the maximum age for qualifying for a catastrophic plan?

30

If some of an electronically submitted claim cannot be adjudicated due to missing data, the insurer must electronically notify the health care provider within what period of time?

7 days of that determination

Under the uniform required provisions, proof of loss under a health insurance policy normally should be filed within

90 days of loss

Which of the following would be considered an unfair claims settlement practice?

A claims adjuster advises the insured that if the claim goes to arbitration, the insured would probably receive less than what is currently being offered

All of the following candidates for resident producer license may be exempted from the examination requirements EXCEPT

A resident producer licensed for Property and Casualty insurance applying for a Life insurance license

Presenting any written or oral statement in support of or in opposition to a claim payment, while knowing that the statement contains false or misleading information material to the claim, would be best considered

A violation of the New Jersey Insurance Fraud Prevention Act. *Presenting false written or oral statements is considered fraud under the New Jersey Fraud Prevention Act. The penalty for a violation of the Act is no more than $5,000 for the first violation, $10,000 for the second violation, and $15,000 for each subsequent violation.

All of the following could qualify as a group for the purposes of purchasing health insurance EXCEPT

An association of 35 people.

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.

All of the following qualify for Medicare Part A EXCEPT

Anyone who is willing to pay a premium

The corridor deductible applies between

Basic and major medical coverage

An applicant gives her agent a completed application and the initital premium. What can the agent issue her that acknowledges the initial premium payment?

Conditional Receipt *When an applicant pays the initial premium before the application is approved and the policy is issued, a conditional receipt can be issued in order to acknowledge the payment. Coverage will not begin, however, until the policy has been issued.

What is the contract provision that allows the insurer to nonrenew health coverage if certain events occur?

Conditionally renewable *The conditionally renewable provision is very similar to the optionally renewable provision. The primary difference is that conditionally renewable policies may be canceled for specific conditions contained in the policy, but optionally renewable policies do not specify a condition or reason for cancellation.

What is the purpose of the gatekeeper in an HMO?

Controlling Costs *Initially the member chooses a primary care physician or gatekeeper. If the member needs the attention of a specialist, the primary care physician must refer the member. This helps keep the member away from the higher priced specialists unless it is truly necessary

A Major Medical Expense policy would exclude coverage for all of the following treatments EXCEPT

Drug addiction

Regarding health insurance, all of the following are tax-deductible EXCEPT

Employee paid group disability income *When the employer pays for group premiums, they are ta-deductible to the employer. When the employee pays for a portion of the group disability premiums, they are not tax-deductible to the employee

The "stop-loss" feature on a major medical policy is intended to

Establish a maximum amount of out-of-pocket expense that an insured will have to pay for medical expense in a calendar year

Most LTC plans have which of the following features?

Guaranteed renewability *The benefit amount payable under most LTC policies is usually a specific amount per day, and some policies pay the actual charge incurred per day. Most LTC policies are also guaranteed renewable; however, insurers do have the right to increase the premiums.

Which of the following refers to nursing and other health care services rendered to a person in his or her residence on a part-time or intermittent basis?

Home health care

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

Occasional nursing or rehabilitative care

With a conditionally renewable policy, the premiums are more likely to be

Increased

Which of the following is NOT true regarding a flexible spending account?

It does not have limits on contributions. *A Flexible Spending Account (FSA) is a form of cafeteria plan benefit funded by salary reduction. The employees are allowed to deposit a certain amount of their paycheck into an account before paying income taxes. FSA benefits are subject to annual maximum and "use-or-lose" rule.

Concerning Medicare Part B, which statement is INCORRECT?

It is fully funded by Social Security taxes (FICA)

Individual health insurance policies must provide all of the following benefits for the treatent of alcoholism EXCEPT

Limited hospital policy benefits *Each policy must include the following benefits for treatment of alcoholism: inpatient or outpatient care in a licensed hospital; treatment at a licensed detoxification facility; confinement as an inpatient or outpatient at a licensed, certified, or state-approved residential treatment facility, under a program which meets minimum standards of care equal to those prescribed by the Join Commission on Hospital Accreditation

All of the following are excluded from coverage in an individual health insurance policy EXCEPT

Mental Illness

Alison wants to buy a health insurance policy. She returns her 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 of the application nor issued the policy *When the agent receives the application and issues a conditional receipt, the insurer has not yet approved the application and issued the policy.

In an individual long-term insurance plan, the insured is able to deduct the premiums from taxes. What income taxation will be imposed on the benefits received?

No tax *Disability income benefits, including those for medical expense and LTC policies, are received income tax free by the individual

A nonresident licensed producer decides to conduct business under an assumed name. Which of the following is true?

Nonresident producers may not conduct business under any name besides legal names. *A resident licensed producer cannot conduct insurance business under a name other than its actual name, unless the name has been filed with the Department. A nonresident licensed producer cannot conduct business under a name other than its legal name in the state where it maintains a residence.

Which of the following are the main factors taken into account when calculating residual disability benefits?

Present earnings and earnings prior to disability

Certain conditions, such as dismemberment or total and permanent blindness, will automatically qualify the insured for full disability benefits. Which disability policy provision does this describe?

Presumptive disability *Presumptive disability is a provision that is found in most disability income policies which specifies the conditions that will automatically qualify the insured for full disability benefits.

Which of the following answers does NOT describe the principal goal of a Preferred Provider Organization?

Provide medical services only from physicians in the network *A Preferred Provider Organization attempts to provide subscribers with a choice of health care provider while effecting some cost-savings by contracting with providers for such services.

What method do insurers use to protect themselves against catastrophic losses

Reinsurance *This is a method where the reinsurer indemnifies the ceding insurer for part or all of the losses it sustains related to a policy issued previously

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

Renewability provision *Renewability provisions are included in each health insurance contract and outlines both the insurer's and insured's right to cancel or renew coverage.

Which statement regarding qualifications for Social Security disability benefits is NOT true?

The individual must be at least 65 years old

Regarding Medicare SELECT policies, what are restricted network provisions?

They condition the payment of benefits

What is the purpose of coinsurance provisions?

To help the insurance company to prevent overutilization of the policy *The purpose of the coinsurance provision is for the insurance company to control costs and discourage overutilization of the policy.

In a group health policy, a probationary period is intended for people

Who joined the group after the effective date. *The probationary period is the waiting period new employees must satisfy before becoming eligible for benefits.

If the owner is not entirely satisfied with the policy issued, she may return it to the insurance company and receive a refund of premium at which of the following time?

Within 10 days of when the policy was delivered. *The free look period begins at the time the policy is delivered