New York State Law
utilization review
A ________________ is a review to determine whether health care services are medically necessary. A ________________ can be undertaken for services that have been provided in the past, are being provided currently, or that will be provided in the future; however, it cannot be undertaken for emergency services.
grandfathered health plan
A ______________________ refers to coverage provided by a corporation in which an individual was enrolled on March 23rd, 2010 for as long as coverage maintains grandfathered status in accordance with the Affordable Care Act.
life settlement broker
A __________________is a person who, in exchange for compensation, negotiates or offers to negotiate a life settlement contract.
Business Entity
A corporation, association, partnership, limited liability company, limited liability partnership, or other legal entity that must designate at least one licensed individual producer to be responsible for compliance with insurance laws, rules and regulations of this state best defines which of the following?
NEVER
An illustration may _____________ project values that are greater than those based on the rate of growth currently being offered.
HMO
- A health service corporation or medical expense indemnity corporation that provides medical, major-medical or similar comprehensive-type coverage will provide coverage for the provision of preventive and primary care services. These services will be provided to a covered child from the date of birth through the attainment of 19 years of age.
evidence of insurability
A former spouse has the right to convert his/her coverage under a family health policy to an individual policy, without providing _________________ by applying and by paying the first premium within 31 days after his/her coverage under the family policy terminates.
privacy policy and practices
A licensee must provide customers with a notice of its ________________________ at the time insurance is applied for and at least annually throughout the term of the customer relationship.
name and address
A life settlement broker may not disclose the the ____________ and ___________ name and address of the of the life insurance policy owner as the privacy of the life insurance policyowner is protected under the law.
10%
An insurance producer may have his/her license suspended or revoked by earning commissions for business written on his/her own property and risks if the commissions received are more than what percentage of the licensee's net aggregate commissions during the preceding 12 months?
31
An insured covered under a group life policy will be allowed to convert to an individual policy, without evidence of insurability, within _________days of the termination or reduction of group coverage.
Renew existing insurance
A temporary insurance license authorizes the licensee to___________ Temporary licensees are not permitted to sell, solicit, or negotiate new insurance.
31 days
An employee or member covered under a GROUP LIFE policy will be allowed to convert to an individual policy, without evidence of insurability, within ______ of the group policy's termination or reduction. *
31
An employee or member covered under a group life policy will be allowed to convert to an individual policy, without evidence of insurability, within ______ of the group policy's termination or reduction. _______ days is for conversion. 30 days is for a grace period. 45 days relates to group health insurance. (Primary member only; dependents have 31 days in health insurance also.) *
31 days
An insured covered under a group life policy will be allowed to convert to an individual policy, without evidence of insurability, within how many days of the termination or reduction of group coverage?*
health status
Annuity suitability information includes age, annual income, investments and other insurance, financial situation and needs, tax status, liquid net worth, and risk tolerance. The consumer's ____________ is NOT required.
group accident
Any policy that insures more than one person against death of injury from accident is considered __________________ insurance EXCEPT: Blanket accident insurance Any individual policy A policy that provides indemnity benefits Family insurance Workers' compensation disability benefits
conflicts
Any provision that, on the policy effective date, __________with insured's state of residence will be amended to conform to the minimum requirements of the state statutes.
40
Applicants seeking a Life, accident, and health insurance license are required to complete how many hours of prelicensing education?
10 days
Before revoking a resident insurance producer's license, how many days' notice must the Superintendent provide to the licensee before holding a hearing?
June 30th
Business licenses expire on _______________ .
cannot
Coverage ____________ be terminated for an unmarried dependent child who is incapable of continuous self-sustaining employment due to mental or physical disability.
pro-rata cancellation
Disability Income and Related Insurance Noncancellable The insurer may cancel the policy during the first 90 days after issue Written notice must be delivered to the insured, or mailed by first class mail, at the last address shown in the insurer's records Notice must provide at least 10 days notice of cancellation The insurer must issue a __________________refund of any premiums paid by the insured Cancellation cannot be issued based on any claims that occurred before the policy's issue date
Group
Eligible _________s An individual employer _________ consisting of the employer's employees A labor union insuring its members A professional, trade, or other association insuring the all eligible members who share the same profession, trade, or occupation for the sole benefit of the members; coverage may only be issued if: At least 100 persons must insured on the date of issue The association has been in existence for at least 2 years and was formed for a primary purpose other than obtaining insurance A customer __________ (i.e., creditors and vendors and including parent holding companies, trusts, and trustees) so long as the amount of indemnity payable to each covered person does not, at any time, exceed: The lesser of $30,000 and the unpaid amount due of the purchase price
12
Family Medical Leave Act (FMLA) The federal Family Medical Leave Act entitles an eligible employee of a covered employer to a family and medical leave insurance benefit for a total of ____ work weeks during any 12-month period
deductibles and coinsurance
HMOs offering medical, major medical, or similar comprehensive insurance must provide coverage for preventive and primary care services without the application of _____________and ______________.
14
Health insurance policies must provide for continuation of benefits as required by law. Within ______ days after receiving notice of an election to continue coverage after any event causing termination of coverage, the applicable employer, policyholder, or agent must notify the insureds of their continuation rights.
small employers
Healthy New York stopped offering coverage to individuals and sole-proprietors and only offers coverage to ___________________. Small group employers must pay at least 50% of the employees' premiums and must offer coverage to all employees receiving annual wages of $30,000 or less. At least 1 employee must accept coverage. All contracts must be community rated and include specified rate tiers.
30
How many days does the policyowner have to return an individual life insurance policy that was sold or issued by direct mail?
coverages or reimbursement
If ____________ or _________________ is provided by an individual, group, or blanket accident and health policy issued in this state, including a contract issued by a hospital service corporation or health service corporation, the following must apply for these services: Optometric Services Podiatrical Services Dental Services Psychiatric or Psychological Services
45
If notice under an employer group health insurance conversion privilege is provided more than 15 days but less than 90 days after termination, the conversion privilege must be extended to 45 days.
coordination of benefits
If the insured has valid coverage providing benefits for the same loss with another insurer, and THIS insurer has not been given written notice prior to the time of the loss, this insurer's liability is limited to a proportion of the loss. Benefits are determined by dividing the total benefits of policies known before the loss by total benefits of all policies known after the loss. This is referred to as the _________________ for individual policies.
reinstatement
If the insured pays a renewal premium after a policy has lapsed, and the insurer does not require a _____________ application, the policy will be reinstated automatically upon acceptance of the premium payment by the insurer or its agent or broker.
45th day
If the insurer requires a reinstatement application and issues a conditional receipt for the premium payment, the policy will be reinstated on the _______________ after the conditional receipt is issued, unless the insurer approves the application or provides a written notice of disapproval before that date.
replacement
If the sale of a life insurance policy involves a ____________, the producer must provide the applicant with all of the following additional documents: Definition of Replacement, Outline of Coverage, and Notice Regarding Replacement.
not liable
Illegal Occupation-The insurer is __________ for any loss if a contributing cause was the insured's engagement in an illegal occupation or commission of, or attempt to commit, a felony.
2 years
In New York, an insurer may void a Individual Health Insurance Policy or deny a claim for misstatements within __________. Once the policy has been in force for ___________ the insurer cannot void the policy or deny a claim based on the misstatements of the applicant in the application unless they are fraudulent misstatements.
It is under 2 years.
In New York, an insurer may void a policy or deny a claim for misstatements under what conditions?
Within 2 years
In New York, an insurer may void a policy or deny a claim for misstatements under what conditions?
At least 18 years old
In New York, applicants for insurance producer and adjuster licenses must be which of the following:
$50,000
In New York, the maximum amount of life insurance that may be issued on the life of a child under age 14½ is _____________
3 yrs
In New York, the period within which one may reinstate a lapsed life insurance policy is:
age 29
In addition, New York law requires insurers issuing hospital, medical, or surgical expense insurance that provide coverage for dependent children to make available a coverage extension for unmarried children until _________if the child is not insured by, or eligible for, employer-sponsored group coverage. This coverage extension must be offered without regard to the child's financial dependence, any self-insurance, place of residency, or the insurer's service area. Insurers must provide written notice of the availability of this coverage extension at least 30 days before the beginning of the policy.
6 months
In some circumstances, life insurance policies can be issued with an effective date up to_______________ in the past to "save" the applicant's age; this process permits the policy's issue age to be one year younger and the policy premium to be correspondingly lower.
2 years
Individual producer licenses expire every _____________ on the licensee's birthday - in even years for producers born in even years and in odd years for producers born in odd years.
Guaranty Corporation
Information about the Life Insurance Company _____________ may be provided upon requested, but cannot be promoted as a reason for buying coverage.
advice
Insurance license Consultants earn compensation for ____________ versus the sale of a policy, and that advice must be provided under terms that are disclosed and agreed to in writing.
15
Insurance producers are required to complete how many hours of approved continuing education during each 2-year license period?
Renewability Clause Provison
Insurers are not permitted to non-renew any policy if one-third or more of the total premium is allocated to hospital, surgical, or major medical benefits unless one or more of the following reasons apply: Non-payment of premiums Fraud or material misrepresentation at the time of applying for insurance or when applying for any policy benefits Discontinuance of a class of policies Discontinuance of all hospital, surgical, and medical expense coverage in the individual market in New York If an insurer offers individual policies through a network plan, an individual no longer resides, lives, or works in the service area of the network - if coverage is terminated uniformly without regard to a health-status related factor
indemnity plans
Major medical insurance is also know as a
supplement Medicare benefits
Medicare supplement insurance is designed to _____________________ and is subject to Medicare guidelines.
20%
New York Tax Credit The State will provide a ________ tax credit toward LTC Partnership premiums. This credit is available to anyone paying long-term care insurance premiums, including children who pay for coverage on behalf of their parents, when they file a New York State tax return.
asset
New York has two ___________ categories: Total Assets and Dollar-for-Dollar.
long-term care partnership program
New York offers residents the opportunity to participate in the New York ____________________. The purpose of a ________________________________ is to encourage consumers to use LTC insurance to fund the costs of long-term care (instead of using Medicaid funds) and to qualify for Medicaid without depleting assets.
Inflation Protection (COLA)
Optional Benefits- _____________________________ New York insurers must offer inflation protection - as either a policy provision or rider - when offering Long-term Care Insurance insurance. Offers of inflation protection to provide for the increase of benefit levels and maximums can be no less favorable to the insured than the following: Increase benefit levels on an annual basis of at least 5% compounded annually (based on the Consumer Price Index) Guarantee the insured the right to periodically increase benefit levels without medical underwriting if the option for such increases wasn't declined by the insured (the minimum amount of any increase must be the difference between the current benefit limit and the current limit compounded annually at a rate of no less than 5%) The benefit level does not include a maximum specified indemnity amount or limit and, instead, covers a specified percentage of actual or reasonable charges
Preferred Provider Organizations
PPO is a_______________
60%
Qualified Health Plan (QHP) A qualified health plan is any plan which provides coverage for the 10 Essential Health Benefits and provides a minimum actuarial value of _______
average earnings
Relations of Earnings to Insurance Loss-of-time benefits cannot exceed the greater of the insured's monthly earnings at the time the disability commenced or the insured's __________________ for the 2 years immediately preceding a disability. The monthly benefit cannot be reduced to less than $200.
community rated
Small group major medical health insurance contracts must be ________________if they provide hospital, medical, and medical benefits.
medical loss ratio
The ACA requires the _______________ to be 85% for large group plans and 80% for individual and small group plans. If an insurer fails the MLR test (the loss ratio is lower than the required minimum) in a calendar year for all plans in a given market segment (individual or group), the excess premium is to be refunded to consumers enrolled in plans in that market segment.
after a hearing
The Superintendent can only revoke a license __________________.
Create insurance laws
The Superintendent has the authority to take all of the following actions EXCEPT? Refer suspected criminal violations to law enforcement officials Create rules to implement and enforce insurance laws Create insurance laws Investigate consumer complaints
$5,000
The Superintendent is authorized to impose a civil penalty up to __________, plus the amount of the claim, for each violation of the Insurance Frauds Prevention Act.
state
The Superintendent's powers are granted by the ____________since insurance is __________ regulated.
equal to
The Total Assets option protects all assets, while the Dollar-for-Dollar option only provides asset disregard that is _____________ the amount of the benefits actually received under the long-term care partnership qualified policy.
Actuarial Value
The _____________________ of a health plan equals the percentage of the total average costs that a plan pays for Essential Health Benefits. I f a health plan had an average _______________of 60%, insured individuals would be responsible for paying 40% of the costs of covered benefits. A plan meets the minimum value requirement if it is designed to pay at least 60% of the total costs for covered benefits.
8 weeks
The benefit cap for New York State Disability Law benefits equals 50% of an individual's wages for the ______________ prior to become disabled.
60 days
The employee or spouse requesting continuation coverage must submit a written election to the employer or policyholder within ___________ of the event that terminated coverage.
2-50
The following type of individual or small group health insurance contracts must be community rated if they provide hospital, surgical, and medical benefits: Individual health insurance contracts Small group health insurance contracts, including Medicare Supplements Small group means _______ employees or group (association) members, excluding spouses and dependents.
2 yrs
The incontestable clause in New York life insurance policies is how long after the policy's issue date?
Grace Period
The insured has a specific period of time after the premium due date to pay the premium before the policy lapses. The _________cannot be less than: 7 days for weekly premium policies 10 days for monthly premium policies 31 days for all other policies
90 days 10 days
The insurer may cancel a policy within the first ___________after it has been issued by providing _________ written notice to the insured. Any unearned premium must be refunded on a pro-rata basis if the insurer cancels the policy; however, if the insured requests cancellation, the premium refund may be on a short-rate basis. The insured may cancel the policy at any time by providing written notice to the insurer.
New York State Disability Benefits
The law provides an eligible person with benefits up to 50% of his/her average weekly wages during the 8 weeks before the onset of disability, subject to a maximum specified dollar amount per week. Benefits begin on the 8th consecutive day of disability and may not extend beyond 26 weeks in any 52-week period.
insurer's claims costs and certain taxes and fees versus its total premiums received
The medical loss ratio is the ratio of an ______________________________________________________________________________. By requiring a minimum MLR, an insurance company provides greater value to its policyholders when a higher percentage of premiums is used for healthcare costs versus administrative expenses or profits.
Buyer's guides
The purpose of the life insurance ______________ help consumers find policies that meet their needs and budgets, decide how much insurance they need, and assist with the process of making informed decisions.
Medicaid Estate Recovery Act (OBRA '93)
This Act requires states to pursue recovering costs for medical assistance consisting of: Nursing home or other long-term institutional services Home and Community based services Hospital and prescription drug services while receiving nursing facility, home and community-based services Any other items covered by the Medicaid State Plan at the state's option At a minimum,states must recover from assets that pass through probate and at a maximum states may recover any assets of the deceased recipient. Partnership program provisions protect policyholders who apply for Medicaid after exhausting their insurance coverage since certain assets are disregarded during their Medicaid eligibility determination. These assets are also exempt from Medicaid claims against their estates after death.
Unpaid Premiums Provision
This provision allows an insurer to deduct any unpaid premiums from claim payments.
Child Health Plus
To be eligible for either Children's Medicaid or __________________, children must be under age 19 and residents of New York. Whether a child qualifies for Children's Medicaid or _______________ depends upon the family's gross income
19
Under individual plans of insurance, dependent children include children under age ___________
50
Under the ACA Employers with more than _____ employees that don't offer an affordable health plan that provides the minimum essential benefits will be required to pay an Employer Shared Responsibility penalty if the government has to subsidize at least one employee's individual plan purchased through an exchange
26 weeks in any 52-week benefit period
Under the New York State Disability Benefits Law, what is the maximum number of weeks one may receive a benefit?
assisted living facility
What is ALF?
skilled nursing facility
What is SNF?
Life settlement broker
What person solicits, negotiates, or offers a life settlement contract in exchange for compensation?
Rebating
What unfair and prohibited practice involves the offer of a special premium or favor as an incentive to purchase insurance?
a portion
When a life insurance policy accelerates benefits, it pays ____________ of the policy's death benefit to the insured during his/her lifetime and the balance of the death benefit to the beneficiary when the insured dies.
Sale / Selling
When an insurance producer exchanges a contract by any means, for money or its equivalent on behalf of a licensed insurer, fraternal benefit society or health maintenance organization, how is the act defined?
Consultants must have a written agreement in place in order to charge a fee
Which of the following statements regarding insurance licenses is true? A Agents earn both consulting fees and commissions from the same sale B Consultants must have a written agreement in place in order to charge a fee C Brokers generally represent the insurer D Public Adjusters work for the state
Insurance with other insurers
Which provision states that if an insured has individual policies with more than one insurer that covers the same claim, both insurers are primary and each will pay the percentage of the claim equal to their percentage of the total coverage available. A Relation of earnings to insurance B Conformity with state statutes C Insurance with other insurers D Coordination of benefits
Coverage
____________ is provided immediately upon reinstatement for accidents and after 10 days for all other losses.
Business of life settlement
_______________- Involves the offering, soliciting, negotiating, procuring, effectuating, monitoring, or tracking life settlement contracts. The business of life settlements also includes: Transactions made via mail or from locations outside this state Conducting any business in a manner that is substantially the same as the business of life settlements for the purpose of evading the provisions of the Life Settlements Act
Blanket accident and health
___________________ insurance insures a group of persons against death or injury arising from accident. Airline, Cruise ship, college campus, city , town, village etc. An association of persons with a common interest or calling - so long as the association has at least 50 members
Insurance Consultant
_____________________: Any person, firm, association, or corporation providing expert and professional insurance advice to clients. Licensed consultants may not solicit, sell, or negotiate an insurance policy, as to do so would require licensing as an agent or broker.
Health Maintenance Organizations
________________________ is an HMO
Benchmark Plans (State Essential Health Benefits)
________________are state specific required benefits, or mandates, include specific care, treatment, or services a health plan must cover.
Stranger-originated life insurance (STOLI)
________________is any act, practice, or arrangement that involves the purchase of insurance with the purpose of benefitting a person who does not have insurable interest in the life of the person to be insured at the time the policy becomes effective. This includes conduct before or at policy issuance. No person is permitted, in any fashion, to engage in any act, practice, or arrangement that constitutes stranger-originated life insurance.
Cost Sharing Reductions
under the ACA _________________must be available on policies purchased through an exchange by consumers with income above 138% of the Federal Poverty Line (FPL) up to 250% of the FPL
