MA Health Insurance
Which statement regarding insurable risk is NOT correct?
Insureds cannot be randomly selected.
All of the following statements about Medicare supplement insurance policies are correct EXCEPT
They cover cost of extended nursing home care -Medicare supplement policies (Medigap) do not cover the cost of extended nursing home care. Medigap plans are designed to fill the gap in coverage attributable to Medicare's deductibles, copayment requirements, and benefit periods. These plans are issued by private insurance companies.
What is the maximum penalty for habitual willful noncompliance with the Fair Credit Reporting Reporting Act?
$2500
An insured's disability income policy includes an additional monthly benefit rider. For how many years can the insured expect to received payment from the insurer before the social security benefits begin?
1 year
An insured pays a monthly premium of $100 for her health insurance. What would be the duration of her grace period under her policy?
10 days - the grace period is 7 days if the premium is paid weekly, 10 days if the premium is paid monthly and 31 days for all other modes.
In order to collect social security disability benefits, the claimant must be able to demonstrate that the disability will last at least
12 months -Social security disability benefits are paid to claimants whose disability is expected to last at least 12 months or lead to death
Within how many days must a career send an insured a written acknowledgement of the receipt of the insured's grievance?
15 days - a carrier must send a written acknowledgment of the receipt of a grievance from the insured within 15 days.
Within how many days must a carrier send an insured a written acknowledgment of the receipt of the insured's grievance?
15 days -A carrier must send a written acknowledgement of the receipt of a grievance from the insured within 15 days
Following hospitalization because of an accident, Bill was confined in a SNF. Medicare will pay full benefits in this facility for how many days?
20 Days Following hospitalization for at least 3 days, if medically necessary, Medicare pays for all covered services during the first 20 days in a SNF. Days 21 through 100 require a daily copayment.
Within how many days of requesting an investigative consumer report must an insurer notify the consumer in writing that the report will be obtained?
3 days -Investigative consumer reports cannot be made unless the consumer is advised in writing about the report within 3 days of the date the report was requested.
How long is an open enrollment period for Medicare supplement policies?
6 months -An open enrollment period is a 6 month period that guarantees the applicants the right to buy Medigap once they first sign up for Medicare Part B
How many eligible employees must be in a contributory plan?
75% At least 75% of eligible completes can be included in a contributory plan. Both the employees and the employer contribute to premium payments.
Any person or organization willfully violating any provision of rate-making provisions of the law will be punishable by
A maximum of $500 for each such violation -Any person or organization willfully violating any provision of the rate-making provisions of the law will be punished by a maximum of $500 per violation.
Which of the following individuals will be eligible for coverage on the Health Insurance Marketplace?
A permanent resident lawful present in the US - To be eligible for health coverage on the marketplace, the individual must be a US citizen or national to be lawfully present in the United States, must live in the United States, and cannot be currently incarcerated. Medicare recipients are not eligible for coverage in the Marketplace.
What document describes an insured's medical history, including diagnoses and treatments?
Attending Physician's Statement -An attending Physician's Statement (APS) is the best way for an underwriter to evaluate an insured's medical history. This report includes past diagnoses, treatments, length of recovery time and prognoses.
All of the following are true regarding Key Employee Disability Income insurance EXCEPT
Benefits are taxable to the employer
In a group prescription drug plan, insured usually pays what amount of the drug cost?
Copayment -Under a group drug plan, the insured typically pays a copay and the insurer pays the balance. There is generally a limit to the quantity of drugs that can be purchased at one time.
When would a misrepresentation on the insurance application be considered fraud?
If it is intentional and material - A misrepresentation would be considered fraud if it is intentional and material. Fraud would be grounds for voiding the contract.
A life insurance policy has a legal purpose if both of the following elements exist?
Insurable interest and consent - to ensure legal purpose of a life insurance policy, it must have both insurable interest and consent
When a person applies for medicare supplement insurance, whose responsibility is it to confirm that the applicant does not already have accident or sickness insurance in force?
Insurer -Although it is illegal for an applicant to intentionally misrepresent himself an insurance, it is the insurer's ultimate responsibility to make sure that the applicant does not already have another accident or sickness policy in force.
Which of the following insurance coverages would be allowed with an MSA?
Long-term Care MSA participants cannot have medicare or any other health coverage that is not a HDHP. Following exceptions are workers compensation, specific disease or illness, a fixed amount per day of hospitalization, accidents and/or disability, dental care, vision care and LTC.
Bob holds himself out to the public as an insurance adviser. He is not duly licensed as an insurance advisor. Such an act is punishable by a fine of
Not less than $50 nor more than $500. Whoever acts as an insurance adviser without a license (or during a suspension of such license) will be punishable by a fine of an amount between $50-$500 or by imprisonment for a maximum period of 6 months (or both)
Premium payments for personally-owned disability income policies are
Not tax deductible premiums for personally-owned individual income policies are not deductible
All of the following are covered by Part A of Medicare EXCEPT
Physician's and surgeon's services. Physicians and surgeons are covered under Part B.
The regulation of the insurance industry primarily resets with
The State -Each state is responsible for the conduct of insurance within that state.
The insure must be able to rely on the statements in the application and the insured must be able to rely on the insure to pay valid claims. IN the forming of an insurance contract this is referred to as
Utmost good faith - The insurer must be able to rely on the statements given by the insured in the application. The insured must be able to rely on the insurer's promise to pay covered losses.
How soon following the occurrence of a covered loss must an insured submit written proof of such loss to the insurance company?
Within 90 days or as soon as reasonably possible, but not to exceed year -The "proof of loss" provision states the claimant must submit a proof of loss within 90 days; however, if it is not possible to comply, the time parameter is extended to 1 year. The one year limit does not apply if the claimant is not legally competent to comply with this provision.
An insurer used fraudulent representations to procure the payment of premiums. What sort of punishment does she face?
A fine of between $100 and $1000 or imprisonment for up to 1 year -In this case, the insurer faces a fine of between $100 and $1000 or imprisionment for up to 1 year
In comparison to. policy that uses the accidental means definition, a policy that uses the accidental bodily injury definition would provide a coverage that is
Broader in general -A policy that uses accidental bodily injury definition will provide broader coverage than a policy that uses the accidental means definition.
Which of the following is NOT a characteristic or a service of an HMO plan?
Contracting with insurance companies -HMOs seek to identify medical problems early by providing preventative care. They encourage early treatment and wherever possible provide care on an outpatient basis rather than admitting the member into the hospital. Contracts are between the insured and the HMP, not an insurance company.
Which of the following is NOT the purpose of the HIPAA?
To provide immediate coverage to new employees who had been previously covered for 18 months -HIPAA does not prohibit employers or providers from establishing waiting periods or pre-existing conditions exclusions, in which case the coverage to new employees would not be immediate.
A licensed person whose activities affect Interstate commerce and knowingly makes false material statements related to the business of insurance may be imprisoned for up to
10 years Anyone engaged in the business of insurance who activities affect interstate commerce and who knowingly makes false material statements may be imprisoned for up to 10 years or both. If the activity jeopardized the security of the accompanied insurer, the punishment can be up to 15 years.
Every small employer carrier must actively offer to small employers at least how many health benefit plans
2 plans - As a condition of transacting business in this state with small employers, every small employer carrier is required to actively offer to small employers at least 2 health benefit plans. One plan offered by each small employer carrier must be basic health benefit plan and one plan must be a standard health benefit plan.
Employer health plans must provide primary coverage for individuals with end-stage renal disease before Medicare becomes primary for how many months?
30 months -The omnibus budget reconciliation act of 1990 as amended by the Balanced Budget Act of 1997 requires the employer health plan to provide primary coverage for 30 months for individuals with end stage renal (kidney) disease before Medicare becomes primary.
Which of the following best describes a misrepresentation?
Issuing sales material with exaggerated statements about policy benefits. Misrepresentation is issuing, publishing or circulating any illustration or sales material that is false, misleading or deceptive as to policy benefits or terms, the payment of dividends, etc. This includes oral statement.s
How is the amount of social security disability benefits calculated?
It is based upon the Primary Insurance Amount (PIA), which is calculated from their Average Indexed Monthly earnings over their highest 35 years.
Health benefit plans are prohibited from including waiting periods that exclude coverage for more than
4 months -similarly, health benefit plans are prohibited from including waiting periods that exclude coverage for more than 4 months (following date of enrollment)
An insured is involved in a car accident. In addition to general, less serious injuries, he permanently loses the use pod his leg and is rendered completely blind. The blindness improves a month later. To what extent will he receive presumptive disability benefits?
Partial Benefits Presumptive disability plans offer full benefits for specified conditions. These policies typically require the loss of use of at least two limbs, total and permanent blindness, or loss of speech or hearing. Benefits are paid, even if the insured is able to work. Because the insured's blindness was only temporary and the loss of use in 1 leg, he does not quality for presumptive disability benefits.
A medical insurance plan in which the health care provider is paid a regular fixed amount for providing care to the insured and does not receive additional compensation dependent upon the procedure performed is called
Pre-paid plan - Under a prepaid plan, the health care providers paid for services in advance whether or not any services are provided. The amount paid to the provider is based upon the projected annual cost as determined by the provider.
What type of health care plan allows insured to select a physician or hospital from a list of providers without being required to submit claim forms?
Preferred Provider Organization -A preferred provider organization is a network of health care providers with whom an employer or insurance company contracts to provide medical services (at a discounted rate). Subscribers to the plan may choose from the list, the physician and hospital from which service is obtained. Usually the subscriber is only required to produce an ID card to verify their status and pay a deductible, if required.
