Chapter 12: Texas Statutes and Rules Pertinent to Accident and Health Insurance Only

Question 1

All individual and group health insurance policies in Texas providing coverage for a family member of the insured or subscriber must provide that health insurance benefits for children will payable for ______ children of the insured from the moment of ______.

Answer 1

1. Newly-Born

2. Birth

Question 2

Notification to the insurer of newborn children must be given within ______ of birth.

Answer 2

31 Days

Question 3

Policies in Texas may not exclude or limit coverage for ______ of a new born child.

Answer 3

Congenital Defects

Question 4

All group health insurance benefit plans in Texas must provide for ______ and ______ addiction treatment on the same basis as the benefits provided for physical illness.

Answer 4

1. Drugs

2. Alcohol

Question 5

In Texas, insurers or agents cannot use questions on the medical application or during the underwriting process that are designed to establish the ______ of the proposed insured, or to determine if the proposed insured has or has been diagnosed as having ______ or ______.

Answer 5

1. Sexual Orientation
2. AIDS
3. AIDS-related complex

Question 6

In Texas, a Medicare supplement policy cannot deny a claim for losses incurred more than ______ from the effective date of coverage because it involved a pre-existing condition.

Answer 6

6 Months

Question 7

In Texas, Medicare supplement policies must have a notice prominently printed on the first page stating that the policyholder has the ______ the policy within ______ (free-look period).

Answer 7

1. Right to Return

2. 30 Days

Question 8

In Texas, all long-term care policies or certificates issued must be ______ or ______. The insured has the right to keep the long-term care insurance in force by making timely payments of premiums, and the insurer may not make any change to the policy or decline to renew it.

Answer 8

1. Guaranteed Renewable

2. Noncancellable

Question 9

The ______ must follow the standard format set out in the insurance regulations including information about the insurance company, the policy number, and important features of the policy.

Answer 9

Outline of Coverage

Question 10

In Texas, with individual or group ______ policies, outlines of coverage must be delivered to the applicant the time of initial policy solicitation or prior to the presentation of the application by the agent.

Answer 10

Long-Term Care (LTC)

Question 11

In Texas, the outline of coverage must specify the terms under which the LTC policy may be returned and premium refunded, and provide a description of the ______ (______) provision under the policy which allows up to ______ to review and return for a full refund of premium.

Answer 11

1. Right to Return (Free-Look)

2. 30 Days

Question 12

Small employer means any person, firm, corporation, partnership, or association that employed at least ______, but not more than ______ eligible employees on business days during the ______.

Answer 12

1. 2
2. 50
3. Preceding Calendar Year

Question 13

Coverage under a small employer group plan is available if ______ of the eligible employees elect to be covered. Small employers that have only 2 employees must have ______ participation in the plan.

Answer 13

1. 75%

2. 100%

Question 14

Insurers may terminate a small employer group’s health plan if the small employer group fails to meet the participation requirement for ______.

Answer 14

6 Months

Question 15

Small group insurance is ______ for its eligible employees and their dependents except for the following reasons:

1. Employer fails to pay premiums.
2. Employer performs a fraudulent act or an intentional misrepresentation.
3. Number of eligible enrollees fall below the minimum participation number.
4. Insurer meets the state requirements for discontinuing the insurance coverage.

Answer 15

Renewable

Question 16

The ______ set up a new competitive private health insurance market.

Answer 16

Patient Protection and Affordable Care Act (PPACA)

Question 17

The ______ holds insurance companies accountable by keeping premiums low, preventing denials of care, and allowing applicants with pre-existing conditions to obtain coverage.

Answer 17

Patient Protection and Affordable Care Act (PPACA)

Question 18

The ______ helps stabilize the budget and economy through reducing the deficit by cutting government overspending.

Answer 18

Patient Protection and Affordable Care Act (PPACA)

Question 19

The ______ extends coverage for dependent children in both individual and group health plans until age 26.

Answer 19

Patient Protection and Affordable Care Act (PPACA)

Question 20

The ______ gives small businesses and nonprofits a tax credit for an employer’s contribution to health insurance for employees.

Answer 20

Patient Protection and Affordable Care Act (PPACA)

Question 21

The ______ prohibits insurance companies from rescinding health coverage when an insured becomes ill, and eliminates lifetime benefit limits.

Answer 21

Patient Protection and Affordable Care Act (PPACA)

Question 22

Specific health coverage plans, such as retiree-only, stand-alone dental plans, Medigap, and long-term care insurance are generally ______ from the PPACA changes.

Answer 22

Exempt

Question 23

To be eligible for health coverage through the ______, the individual:

1. Must be a U.S. citizen or national or be lawfully present in the U.S.
2. Must live in the U.S.
3. Cannot be currently incarcerated.

Answer 23

Health Insurance Marketplace

Question 24

If an individual has Medicare coverage, that individual IS / IS NOT eligible to use the Marketplace to buy a health or dental plan.

Answer 24

IS NOT

Question 25

The ACT established ______ that administer health insurance subsidies and facilitate enrollment in private health insurance, Medicaid, and the Children’s Health Insurance Program (CHIP).

Answer 25

Insurance Exchanges

Question 26

A(n) ______ can help the applicant:

1. Compare private health plans.
2. Obtain information about health coverage options to make educated decisions.
3. Obtain information about eligibility or tax credits for most affordable coverage.
4. Enroll in a health plan that meets the applicant’s needs.

Answer 26

Exchange

Question 27

When health insurers set their ______ rates, they are only permitted to base those rates on 4 ______:

1. Geographic rating area (location of residence within the state).
2. Family composition (single or family enrollment).
3. Age.
4. Tobacco use.

Answer 27

1. Premium

2. Standards

Question 28

After submitting an application for health insurance for a qualified health plan, individuals will be able to a(n) ______ to reduce the cost of their health care coverage if purchased through an exchange.

Answer 28

Advance Tax Credit

Question 29

Legal residents and citizens who have incomes between ______ and ______ of the Federal Poverty Level (FPL) are eligible for the tax credits.

Answer 29

1. 100%

2. 400%

Question 30

Persons who are eligible for a premium tax credit and have household incomes between ______ and ______ of FPL are eligible for cost-sharing subsidies (reductions).

Answer 30

1. 100%

2. 250%

Question 31

Small employers that offer health plans may be eligible for federal tax credits. These tax credits, available to low-wage employers (under ______ average per employee) with 25 or fewer workers, may cover up to ______ of premiums paid for small business employers and ______ of premiums paid for small tax-exempt employers.

Answer 31

1. $50,000
2. 50%
3. 35%

Question 32

Originally, the ACA required all U.S. citizens and legal residents to have qualifying health care coverage. This was known as the ______, and was part of the Act’s ______.

Answer 32

1. Individual Mandate

2. Shared Responsibility Provision

Question 33

As of 2019, the individual mandate and shared responsibility penalty ______. However, many states have their own individual health insurance mandate. In these states, an individual must have qualifying health coverage or pay a(n) ______.

Answer 33

1. No Longer Apply

2. State Tax Penalty

Question 34

If an employer (50+ full-time employees) does not offer coverage and at least one employee receives a premium tax credit, the employer is fined ______ per full-time employee (first ______ employees are excluded).

Answer 34

1. $2,000

2. 30

Question 35

If an employer (50+ full-time employees) offers coverage and at least one employee receives a premium tax credit, the employer is fined the lesser of ______ per employee who receives a premium tax credit or ______ per each full-time employee (first ______ employees are excluded).

Answer 35

1. $3,000
2. $2,000
3. 30

Question 36

The Affordable Care Act (ACA) requires that all health care plans include the following ______:

1. Ambulatory patient services.
2. Emergency services.
3. Hospitalization.
4. Maternity and newborn care.
5. Mental health and substance use disorder services.
6. Prescription drugs.
7. Rehabilitative and habilitative services and devices.
8. Laboratory services.
9. Preventive and wellness services.
10. Pediatric services, including oral and vision care.

Answer 36

Essential Benefits

Question 37

______ stipulates that the financial requirements (such as coinsurance) and treatment limitations imposed on mental health and substance use disorder benefits cannot be more restrictive than the requirements and treatment limitations that apply to all other medical and surgical benefits.

Answer 37

Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)

Question 38

______ coverage is an essential health benefit under the ACA that must be available as part of a health plan or as a stand-alone plan for children 18 or younger.

Answer 38

Pediatric Dental

Question 39

Most health plans must cover a set of ______ like shots and screening tests at no cost to the insured. This includes Marketplace private insurance plans.

Answer 39

Preventive Services

Question 40

Newborn children must be covered from the moment of ______.

Answer 40

Birth

Question 41

Insurers must be notified of a newborn within ______ of birth.

Answer 41

31 Days

Question 42

Coverage for ______ and ______ treatment must be provided on the same basis as physical illness.

Answer 42

1. Drug

2. Alcohol

Question 43

______ test results may not be released without consent of the applicant.

Answer 43

HIV

Question 44

Written notice of positive ______ test results must be provided to the designated physician of the insured or to the Texas Department of Health.

Answer 44

HIV-Related

Question 45

Medicare supplement policies cannot deny a claim for loses incurred ______ before the effective date of coverage.

Answer 45

6 Months

Question 46

Coverage on a spouse cannot be ______ upon the termination of the insured’s coverage, except for nonpayment of premium.

Answer 46

Terminated

Question 47

Medicare supplement policies are ______.

Answer 47

Guaranteed Renewable

Question 48

Medicare supplement policies must give notice of the insured’s right to return a policy within ______ for a full refund (known as the ______).

Answer 48

1. 30 Days

2. Free-Look Period

Question 49

Medicare supplement policies must contain a(n) ______ or ______ provision, stating the rights of the insurer to change premiums and any automatic renewal premium increases based on the insured’s age.

Answer 49

1. Renewal

2. Continuation

Question 50

______ and ______ of long-term care coverage must appear on the first page of a policy.

Answer 50

1. Renewability

2. Duration

Question 51

Long-term care policies must be ______ or ______.

Answer 51

1. Guaranteed Renewable

2. Noncancelable

Question 52

Agents must give out a(n) ______ when selling long-term care insurance.

Answer 52

Outline of Coverage

Question 53

LTC policies must have a(n) ______ free-look period, during which the insured may return the policy for a full refund.

Answer 53

30-Day

Question 54

______ is a person, firm, corporation, partnership, or association which employs at least 2 but no more than 50 eligible employees during the preceding year.

Answer 54

Small Employer

Question 55

Coverage under a small employer group plan may only be available if at least ______ of employees participate.

Answer 55

75%

Question 56

If a small group fails to meet participation requirements for ______, the insurer may terminate the group’s health benefits.

Answer 56

6 Months

Question 57

Small group insurance is not ______ if an employer fails to pay premiums, performs fraudulent acts, fails to comply with contribution limits, the number of employees does not qualify, or the insurer meets other state requirements for discontinuation.

Answer 57

Renewable

Question 58

Small employer insurers must provide at least ______ standard benefit plans.

Answer 58

Two

Question 59

The ______ is commonly called the Affordable Care Act (ACA for short).

Answer 59

Patient Protection and Affordable Care Act (PPACA)

Question 60

The ______ requires all persons residing in the U.S., age 18 or older, to have health insurance, or pay a penalty tax on their tax return.

Answer 60

Individual Mandate

Question 61

The ACA requires children to remain dependents on their parents’ health insurance policy up until age ______, regardless of dependency, martial status, or college status.

Answer 61

26

Question 62

The ______ are electronic websites that allow both individuals and small businesses a place to procedure health insurance coverage.

Answer 62

Marketplaces

Question 63

ACA ______ may vary based upon the following factors:

1. Age (older people may be charged more than young people).
2. Geographic location.
3. Tobacco use.
4. Individual vs. family enrollment.
5. Plan category (bronze, silver, gold, platinum, catastrophic).

Answer 63

Premiums

Question 64

There are two cost reduction measures that are available when a person qualifies based on need and buys coverage on a Marketplace: a(n) ______ and a(n) ______.

Answer 64

1. Premium Tax Credit

2. Cost-Sharing Subsidy

Question 65

The ______ requires health benefit plans to include coverage for these 10 ______:

1. Ambulatory patient services.
2. Emergency services.
3. Hospitalization.
4. Laboratory services.
5. Maternity and newborn care.
6. Mental health and substance use disorder services.
7. Pediatric services, including oral and vision care.
8. Prescription drugs.
9. Preventive and wellness services.
10. Rehabilitative and habilitative services and devices.

Answer 65

1. ACA

2. Essential Health Benefits

Question 66

The coverage offered to employees must also include an offer of coverage for the employee’s ______.

Answer 66

Dependents

Question 67

A full-time employee under the ACA is one who works ______ or more on average, per week.

Answer 67

30 Hours

Question 68

An employer subject to the Act that does not offer health coverage to full-time employees and dependents will face a(n) ______ (penalty).

Answer 68

Employer Shared Responsibility Payment

Question 69

An employer that offers health coverage to only employees but not dependents may face a(n) ______ (penalty)

Answer 69

Employer Shared Responsibility Payment