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
