Basic Health
Medicare Part D =
"Stand alone" drug insurance for ppl who need coverage AND are eligible for Part A and/or Part B
An employee insured under a group health plan has been paying $25 monthly premium for his group health coverage. The employer has been contributing $75 for the total monthly cost of $100. If the employee leaves the company, what would be his maximum monthly premium for COBRA coverage?
$102
An insured has a major medical policy with a $500 deductible and a coinsurance clause of 80/20. If he incurs medical expenses of $4000, the insurer would pay
$2800
What is the period of coverage for events such as death or divorce under COBRA?
36 months
A Medicare supplement policy must provide coverage for pre-existing conditions after the policy has been in force for
6 months
In order for costs to be covered under a dental plan, what is the minimum interval that must pass between routine dental exams?
6 months
All of the following can qualify as a trust EXCEPT
An employer insuring at least 5 employees for the benefit of that employer A group health insurance policy trust cannot benefit the employer
While a claim is pending the insurance company may require
An independent examination as often as reasonably required
Under HIPAA, which of the following is INCORRECT regarding eligibility requirements for conversion to an individual policy?
An individual who was previously covered by group health insurance for 6 months is eligible.
Under a Key Person disability income policy, premium payments
Are made by the business and are not tax deductible
What document describes an insured's medical history, including diagnoses and treatments?
Attending Physician's Statement
Occasional visits by which of the following medical professionals will NOT be covered under LTC's home health care?
Attending physician (Community based services = HOSPICE)
Which of the following is not an enrollment period for Medicare Part A applicants?
Automatic enrollment
Of the following choices, which of the statements about occupational versus nonoccupational cover is true?
Disability insurance can be written as occupational or nonoccupational
OBRA requires which disease to be covered by an employer for 30 months before Medicare becomes the primary mode of coverage
End-stage renal failure
In an optionally renewable policy, the insurer has which of the following options?
Increase premiums
What statement best describes the free look provision?
It allows the insured to return the policy within 10 days for a full refund or premiums if dissatisfied for any reason
Which of the following statements is NOT true concerning medicaid? A. Intended to provide medical assistance for needy B. It consists of 3 parts: Part A: Hospitalization Part B: doctor's services, Part C: disability income C. State program D. Paid for by state taxes
It consists of 3 parts: Part A: Hospitalization Part B: doctor's services, Part C: disability income
Which of the following is true regarding the taxation of the premium in group accidental death and dismemberment policies?
It is deductible as an ordinary business expense
Which is true regarding HMO coverage?
It is divided into geographic territories
Julie must have orthodontic work performed on her incisors. Which type of service would this be called, under a nonscheduled plan?
Major service
In group insurance, what is the policy called?
Master Policy
Medicare Part B =
Medical Insurance protection
Medicare Part C =
Medicare Advantage (Medicare + Choice)
Medicare Advantage is also known as
Medicare Part C
Bethany studies in England for a semester. While she is there she is involved in a train accident that leaves her disabled. If Bethany owns a general disability policy, what will be the extent of benefits that she receives?
None General disability policies do not cover losses caused by war, military service, intentionally self-inflicted injuries, overseas residence, or injuries suffered while committing or attempting to commit a felony.
An insured does not have to pay coinsurance or deductibles on a full-series mouth x-ray, but does have to pay a deductible to get his cavities filled. Which dental plan does he have?
Nonscheduled
Which law was passed to authorize the NAIC to develop a standardized model for Medicare supplement policies?
OBRA
Which renewal option does NOT guarantee renewal and allows the insurance company to refuse renewal of a policy at any premium due date?
Optionally renewable
Under which of the following organizations are the practicing providers compensated on a fee-for-service basis?
PPO PPO is contract on a fee-for-service basis
Which of the following factors would be an underwriting consideration for a small employer carrier?
Percentage of participation Coverage under a small employer health benefit plan is generally available only if at least 75% of eligible employees elect to be covered.
Any occupation disability typically means that an individual is unable to perform the duties of the occupation for which he/she is suited by all of these EXCEPT
Preference
After the elimination period, a totally disabled insured qualified and started receiving benefits from his disability income policy that has a waiver or premium rider. What will most likely happen to the premiums paid into the policy during the elimination period?
Premiums will be refunded
Which of the following are the main factors taken into account when calculating residual disability benefits?
Present earning and earning prior to disability
Under a disability income policy, the insurer pays a monthly benefit that is less than the insured's income. What is the reason for that?
Prevent over utilization and malingering.
Rose bought three policies from the same insurer. Her benefits have exceeded the max allowed by the insurer. Which of the following will happen?
Pro rata benefit reduction
Under which provision can a physician submit claim information prior to providing treatment?
Prospective reveiw
What would a physician utilize if he/she wanted to know if a treatment is covered under an insured's plan and at what rate it will be paid?
Prospective review (precertification provision)
A husband and wife are insured under group health insurance plans at their places of employment. Because their employers pay for their plans, each is covered as a dependent under their spouse's coverage. If the husband is hospitalized, how are the medical expenses likely to be paid?
The benefits will be coordinated. Benefits will be coordinated when individuals are covered under two or more health plans.
most scheduled plans provide first dollar benefits without
coinsurance and deductibles
Combination plans are comprised of two types of plan featuers: basic and
comprehensive
The free-look provision allows for which of the following?
A right to return the policy for a full premium refund
An insured is covered under 2 group health plans - under his own and his spouse's. He had suffered a loss of $2000. After the insured paid the total of $500 in deductibles and coinsurance, the primary insurer covered $1500 of medical expenses. What amount, if any, would be paid by the secondary insurer?
$500 Once the primary insurer has paid their full available benefit, the secondary insurer will cover what he first company won't such as deductibles and coinsurance.
What is the shortest possible elimination period for group short-term disability benefits provided by an employer?
0 days
According to OBRA, what is the minimum number of employees required to constitute a large group?
100
S is a sole business proprietor who owns a medical expense plan. What percentage of the cost of the plan may he deduct?
100%
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
COBRA applies to employers with at least
20 employees
under a nonscheduled plan what portion of balance could an insurance expect to pay for basic services?
20%
Following an injury, Jill, age 66 and covered under Medicare Parts A and B, was treated by her physician on an out-patient basis. How much of her doctor's bill will Jill be required to pay out-of-pocket?
20% of covered charges about the deductible
Lisa and Lena own a shop together. They are partners in their business of 2 years. Lisa is a designer, Lena is a seamstress. Lisa worries that if Lena becomes disables, that would affect their business. She inquires about purchasing disability buy-sell insurance. What does her agent tell her about that type of policy?
A disability buy-sell plan protects the insured in case of disability. It allows the policyowner to buy out the partner's interest in the business, and the benefits are tax free.
All of the following are correct about the required provisions of health insurance policy EXCEPT A) Proof-of-loss forms must be sent to the insured within 15 days of notice of claim B) A grace period of 31 days is found in an annual pay policy C) The entire contract clause means the signed application, policy endorsements, and attachments constitute the entire contract D) A reinstated policy provides immediate coverage for an illness
A reinstated policy provides immediate coverage for an illness
Which of the following statements is not true of a Combination Dental Plan? A. A combo plan is also known as "superimposed plan" B. Combo plan is basically a combo of a schedule and nonschedule plan C. Combo plan covers diagnostic and preventive care on the usual customary and reasonable basis D. Combo plan uses a fee schedule for other dental services
A. A combo plan is also known as "superimposed plan"
All of the following statements concerning workers compensation are correct EXCEPT A. Benefits include medical, disability income, and rehabilitation coverage B. A worker receives benefits only if the work related injury was not his/her fault C. Workers compensation laws are established by each state D. All states have workers compensation
B. A worker receives benefits only if the work related injury was not his/her fault
Medicaid provides all of the following benefits EXCEPT A. Family Planning Services B. Income assistance for work-related injury C. Home health care services D. Eyeglasses
B. Income assistance for work-related injury
All of the following are ways in which a Major Medical policy premium is determined EXCEPT A. The stop loss amount B. The average age of the group C. Amount of the deductible D. Coinsurance percentage
B. The average age of the group
What two types of services are under nonscheduled
Basic and major
A dental plan that provides coverage based upon a specified max scheduled amount for each procedure and pays on a "first dollar" basis with no deductible or coinsurane is a
Basic or scheduled plan
John owns a medical expense policy that he purchased for his family. John's employer purchased a Group Disability Income policy for John and all eligible employees. John subsequently suffered an accident on the job that left him unable to work for four months. If John receives benefits from his disability income policy, which of the following would be true?
Benefits received that are attributable to employer contributions are fully taxable to the employee as income.
An individual is insured under his employer's group Disability Income policy. The insured suffered an accident while on vacation that left him unable to work for 4 months. If the disability income policy pays the benefit, which of the following would be true?
Benefits that are attributable to employer contributions are fully taxable to the employee as income.
A business wants to make sure that if a key employee becomes disabled, the business will be protected from any resulting loss. Which kind of insurance will protect the business?
Business Disability
Kevin and Nancy are married, Kevin is the primary breadwinner and has a health insurance policy that covers both him and his wife. Nancy has an illness that requires significant medical attention. Kevin and Nancy decide to legally separate, which means that Nancy will no longer be eligible for health insurance coverage under Kevin. Which of the following options would be best for Nancy at this point?
COBRA
A man is injured while robbing a convenience store. How does his major medical policy handle the payment of his claim?
Claim is denied if his policy contains the Illegal Occupation provision
What process will the insurance company use to monitor the insured's hospital stay to make sure that everything is proceeding according to schedule?
Concurrent review
When Ken purchased his health policy he was a window washer. He has since changed occupations and now manages a library. Upon notifying the insurer of his change of occupation the insurer should
Consider decreasing the premiums
All of the following are usually provided under an employer group dental insurance plan EXCEPT
Coverage for cosmetic treatment
Which of the following conditions would a disability income policy most likely NOT require in order to qualify for benefits? A. The insured must be under a physicians care B. The insured must be confined to the house C. The insured must provide proof of disability D. A specified income status prior to the disability
D. A specified income status prior to the disability
Which of the following is not true regarding uniform mandatory provisions concerning claims? A. If the insured is several days late in filing proof of loss form, the claim cannot be denied if the insured can show good cause B. The insured is customarily required to give notice of claim within 20 days C. If the insured is 2 years late in filing proof of loss, the claim can be denied D. An insured must notify the insurer of a claim on forms prescribed by the insurer
D. An insured must notify the insurer of a claim on forms prescribed by the insurer
Which of the following is not considered a basic service under a nonscheduled plan
Dentures
What type of group rating uses the actual experience of the group as a factor in developing the rates to be charged?
Experience rating
Alden is involved in a small plane accident that renders him permanently deaf, although he does not sustain any other major injuries. Alden is still able to perform his current job. To what extent will he receive Presumptive Disability benefits?
Full benefits
What option allows the insured to periodically increase benefit levels without providing evidence of insurability?
Guarantee of insurability
A new employee who meets HIPAA eligibility requirements must be issued health coverage on what basis?
Guaranteed If a new employee is eligible, under HIPAA regulations, the new employer must offer coverage on a guaranteed issue basis.
Medicare Part A =
Hospital Insurance protection
Which of the following is incorrect concerning taxation of disability income benefits?
If paid by the individual, the premiums are tax deductible.
A child of the insured is incapable of self support because of a physical handicap. The child has reached the limiting age for dependent. When can coverage continue under the health insurance policy?
If premium is paid, and the proof of the dependent's handicap is provided within a specified period of time
When an employee is still employed upon reaching age 65 and eligibility for Medicare, which of the following is the employee's option?
Remain on the group health insurance plan and defer eligibility for Medicare until retirement
Which health insurance provision describes the insureds right to cancel coverage
Renewal Provision
Which of the following are responsible for making premium payment in an HMO plan?
Subscribers Subscribers are people in whose name the contract is issued. They would be responsible for making premium payments.
Which of the following is NOT an activity of daily living (ADL)?
Talking
Income benefits in a disability income policy are characterized by all of the following EXCEPT
The amount to be paid is unlimited
Which of the following statements concerning group health insurance is CORRECT?
The employer is the policyholder
In a group policy, who is issued a certificate of insurance?
The individual insured
A man works for Company A and his wife works for Company B. The spouses are covered by health plans through their respective companies that also cover the other spouse. If the husband files a claim
The insurance through his company is primary
In which of the following cases would an "any occupation" disability income policy pay the benefits?
The insured is unable to perform any jobs in the field related to the insured's education and experience.
A man is enrolled in Part A of Medicare and not Part B. Three months into coverage, he applies for a Medicare supplement policy Which of the following is true?
The insurer can deny coverage
An insurer would like to add a provision to its individual health insurance policies. This particular provision would be consistent with uniform provisions. Which of the following is true?
The provision would be allowed, as long as it is approved by the state
Which of the following is true regarding METs?
They allow several small employers purchase less expensive insurance together. MET = Multiple Employer Trust
When employees are actively at work on the date coverage can be transferred to another insurance carrier, what happens to coinsurance and deductibles?
They carry over from the old plan to the new plan.
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 since changed?
They no longer have to offer HMO as an alternative plan
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
A medical expense policy that establishes the amount of benefit paid based upon the prevailing charges which fall within the standard range of fees normally charged for a specific procedure by a doctor of similar training and experience in that geographic area is known as
Usual, customary and reasonable. The usual, customary and reasonable approach for determining insurance benefits is based upon the fees normally charged for specific procedures in the geographic location where the services are provided.
All of the following cases show when a Small Employer Medical plan cannot be renewable EXCEPT
When the employer chooses to renew the plan
What is Concurrent Review process?
When the insurance company monitors the insureds hospital stay to make sure that everything is preceding according to schedule and that the insured will be released from the hospital as planned
When is the insurability conditional receipt given?
When the premium is paid at the time of application
An employee is injured in a construction accident, rendering him unable to work for a year. Which of the following plans would provide him with medical expense coverage and income assistance?
Workers Compensation
Can an individual who belongs to a POS plan use an out-of-network physician?
Yes, and they may use any preferred physician, even if not part of the HMO
which of the following is not applied toward the deductible under a nonscheduled plan>?
annual dental exam
under most dentist plans what limitations are posed for denture replacement?
once every 5 years
what clause allows both the insured and the dentist to know in advance which benefits will be paid?
precertification
