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Accident & Health > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

In a non contributory group disability income insurance plan, what is the tax treatment of benefits received by an employee

A

Benefits are included in the employee’s gross income.

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2
Q

The insurance code definition of an “Insurance Broker” is

A

Someone paid to transact insurance on behalf of another person but not on behalf of the insurer.

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3
Q

If an employee elects to continue group health coverage under COBRA after a qualifying event, how long must the employer continue coverage for that employee under COBRA and what percentage of premium can the employee be required to pay

A

18 months/ 102%

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4
Q

Vision care insurance usually covered all of the following excluding one

Eyeglass frames
Eye examinations
Eye surgery
Contact lenses

A

Eye Surgery

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5
Q

Under an individual health guaranteed renewable contract, the insurer has the right to:

A

Change premiums for the same class of insureds.

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6
Q

How many Medicare supplement (Medigap) plans are there?

A

10

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7
Q

What is PPACA

A

Federal statute (Patient Protection & Affordable Care Act) involving major reforms to health care.

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8
Q

After receiving your insurance license, if you change your address, you are to notify the commissioner

A

Immediately

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9
Q

What provision prevents a family from receiving benefits from two separate group policies with the same medical expense

A

Coordination of benefits

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10
Q

A hospital confinement indemnity insurance policy pays:

A

The daily benefit coverage amount stated in the policy for each day the insured is confined in the hospital

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11
Q

All of the following statements about the gatekeeper system are true, EXCEPT:

The insured must utilize their primary physician who authorize all care for the insured.

Gatekeeper are a common feature of HMO plans.

Referrals to specialists must be authorized by the gatekeeper

Specialist can choose to be gatekeepers for their patients

A

Specialist can choose to be gatekeepers for their patients.

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12
Q

Under PPACA, what is a health benefit exchange?

A

PPACA creates new entities called American Health Benefits Exchanges through which individuals. Small business. And those whoso not have have access to affordable employer coverage, can purchase coverage.

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13
Q

According to Employee Retirement Income Security ACT of 1974 (ERISA) fiduciary standards, benefits plans are operated for:

A

Plan participants and beneficiaries

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14
Q

Under the Consolidated Omnibus Budget Reconciliation ACT (COBRA), a qualifying event ensures that an employee who is covered can:

A

Elect to continue coverage

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15
Q

When medical expense policies do not state specific dollar benefit amounts, but instead base payments upon charges for like services in the same geographical area? Benefits are designated as

A

Usual, customary, and reasonable charges.

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16
Q

How many days is allowed by law for an insurance firm to supply claim forms to the person submitting a claim?

A

15

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17
Q

Which coverage is available at no cost to person at age 56?

A

Medicare part A

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18
Q

Part time nursing care that follows a hospitalization and can be provided in a patient’s home is covered under

A

Home health care benefits

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19
Q

Hospital Acutue Care Unit is covered by a LTC insurance policy true or false

A

True

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20
Q

A representation in an insurance contract qualifies as which if the following?

A

An implied warranty

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21
Q

A disability income policy social insurance supplement (SIS) benefits rider

A

Provides a benefit if the insured does not qualify for social insurance benefits

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22
Q

In a reinsurance agreement the insurer that transfers its loss exposure to another is called the

A

The Primary insurer

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23
Q

Disability income insurance payments are based on

A

An out agreed upon by the insurer and the insured.

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24
Q

What is a morbidity table?

A

A table that has information on the probability of disabilities because of sickened or accidents

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25
Q

What is true regarding an aleatory contract?

A

If there were a loss, the insurer would pay out considerably more compared to the insured premium.

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26
Q

Unless it is merely a statement of an expectation of a belief, a representation as to the future is considered what?

A

Promise

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27
Q

Any time a long term care policy is replaced, the sales commission paid to the agent by the insurer shall be calculated based on

A

The difference between the annual premium of the replacement coverage and the original coverage

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28
Q

Medicare Part A doesn’t provide coverage for

A

Physicians services

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29
Q

Which health plan pays more for care received from a network provider than it pays for care from a non network provider?

A

Preferred Provider Organization (PPO)

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30
Q

Are low income families eligible to participate in the California Health Benefit Exchange program ?

A

Yes, using tax credits and if the low income family/individual’s income is between 133 - 400% of the federal poverty level

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31
Q

An insured has a disability insurance policy and he changed to an occupation with less risk than the previous one his insurer will:

A

Keep the policy the same.

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32
Q

Unless certified by another governmental agency, which entity has jurisdiction over provider of coverage designed to pay for health care services

A

The Department of insurance.

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33
Q

A form of rest or relief offered to family members who are caring for a person who requires continual care is

A

Respite care

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34
Q

Members of the medical information Bureau are REQUIRED to report

A

Medical impairments found during the underwriting process

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35
Q

Certain health providers are called “service type providers” this means

A

Payment for services are made directly to the provider

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36
Q

I’m insurance terms a representation can be considered

A

An implied warranty

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37
Q

Which plan covers the medical expenses that are not covered by Medicare ?

A

Medicare supplement

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38
Q

When an agent takes an application or receives premium moneys for an application, including a health policy, the insurance code specifically requires the agent to disclose to the insured or applicant

A

The effective date of coverage, if known, or the circumstances under which coverage will be effective

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39
Q

A long term care insurance rider cannot include coverage for

A

hospital acute care

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40
Q

Under a disability income insurance policy with an own occupation clause, an individual who can no longer perform the task of the job held at the time of injury is considered

A

Totally disabled

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41
Q

By putting a maximum limit on how much is covered under a policy for certain selected coverages, an insurance company can try to avoid:

A

Over insurance

42
Q

Insurance negatively affect Soviet in what way

A

Paid claims do not actually replace the damages as a whole

43
Q

Which of the following plans are claim forms typically completed and submitted by the participant?

1.Health Maintenance Organizations
2. Point of service
3. Preferred Provider Organizations
4. Indemnity

A

Indemnity

44
Q

What is not allowed by code in connection with the sale of Medicare supplement policies?

A

Offering Only Broader Plans

45
Q

Which plan covers the medical expenses that are not covered by Medicare?

  1. Long term care
  2. Medicare Supplement
  3. Disability income
  4. Medi- Cal
A

Medicare supplement

46
Q

The clause that states that an insured is to provide the health insurer a written notice of claim that will be forthcoming is the

A

Notice of claim -20 days

47
Q

A long term care insurance rider can include coverage for all of the following except

1.Respite care
2. Hospital acute care
3. Hospice
4. Adult day care

A

Hospital acute care

48
Q

An exclusion of benefits in health and disability insurance that denies coverage for a stated period of time for conditions that were experienced before the policy became effective is the :

A

Preexisting conditions exclusion

49
Q

What is a morbidity table?

A

A table that has Information of the probability of disabilities because of sickness or accidents.

50
Q

If there were a loss, the insurer would pay out considerably more compared to the insured’s premium what kind of contract is this referring to?

A

Aleatory contract

51
Q

On which date does the authority given to a licensee from an insurer to transact insurance become effective

A

The date the insurer signs the notice appointment.

52
Q

Description of a hazard is a/an:

A

Conditions that may increase the chance that a loss may occur

53
Q

The HICAP (The Health Insurance Counseling & Advocacy Program) provides assistance for a fee based upon ability to pay TRUE or FALSE

A

FALSE

54
Q

A person has a disability policy with the following definition of disability: “the inability to perform any occupation for which the insured is suited through education, training, experience or prior economic status.” This is an:

A

Any occupation definition and very restrictive

55
Q

A self insured group qualifies for stop-loss coverage after claims

A

Exceed a specifics limit in a set period of time

56
Q

A health insurance copayment is:

A

A payment paid by the insured to provider for the service.

57
Q

A disability policy, described as “Guaranteed renewable” is on where the insurance company:

A

Reserves the rights to change the premiums, but may not change any of it term.

58
Q

The usual elimination (waiting) period for a disability income rider is:

A

Three to six months

59
Q

Self funding of employees benefits plans cannot be used for:

A

Death Benefits

60
Q

Medicare Part A will send a statement to which of the following ?

A

Insured

61
Q

All of the following statements about Medicare part B are correct

  1. Pay for physician services.
  2. Pays for virtually all drugs prescribed by a physician
  3. Is optional to those enrolling in Medicare Part A
  4. Requires a premium payment
A

Pays for virtually all drugs prescribed by physicians.

62
Q

A health maintenance organization (HMO) plan contains cost by promoting

A

Preventative care

63
Q

Long term care policy that have the highest premium.

A

Long term period

Short elimination period

64
Q

What kind of insurance pays medical benefits only in the event the insured sufferes from one stipulated disease

A

Specified Disease

65
Q

How would a peril best be defined

A

Reason for the loss

66
Q

The insurer can cancel A policy under a non cancel able health insurance policy
True or False

A

True

67
Q

The basic feature of an indemnity plan is that the participants:

A

Select a provider and submit to the insurance company

68
Q

In medical expenses insurance, what serves the sane purpose as the elimination period In disability income insurance ?

A

Deductible

69
Q

The federal act that is designed to protect group plan participants,establish pensions equality, and mandate s strict reporting and disclosure requirements

A

ERISA

70
Q

When are parties to a contract required to communicate information solely based on personal judgment for a matter in question

A

Never

71
Q

Self funding of employees never needs no

A

Death brought

72
Q

After receiving care by a physician, how is a patient notified of a Medicare decision to cover it

A

Medicare Summary Notice (MSN)

73
Q

Loss retention is an effective risk management technique when all of the following conditions exist.

A

1.The losses are highly predictable
2.The insured chooses to assume the losses involved
3. The worst possible loss is not serious

74
Q

The life analyst is allowed to charge a fee for services provided as long as it is stated in writing in advance of performing the service. Each of the following must be included in this written agreement, Except

A

(A)The services which will be performed and provided, but for which no fee will be charged.

The information being analyzed can be obtained directly from the insurer at no charge

The commissions received for the sale of products

The exact fee to be charged

75
Q

If a policy has a 90-day elimination period when will a check be cut?

A

On the 121st day

76
Q

Group health plans obligate by the consolidated Omnibus Budget Reconciliation Act (COBRA) cover groups of at least

A

20 Employees

77
Q

Under the consolidation Omnibus Budget Reconsolidation Act (COBRA) which of the following is a qualifying event?

Promotion

Divorce

Relocation

Marriage

A

Divorce

78
Q

The Employee Retirement Income Security ACT of 1984 (ERISA) regulates group health insurance in the area of

A

Disclosure and Reporting

79
Q

The Employee Retirement Income Security ACT of 1984 (ERISA) requires plan sponsor to provide participants with

A

Plan descriptions and benefits statements

80
Q

A health insurance copayment is

A

A payment paid by the insured to the provider for the service

81
Q

Under The Consolidated Omnibus Budget Reconciliation ACT (COBRA) how many months of coverage are available?

A

Eighteen Months

82
Q

What is covered by Part A Medicare ?

A

Hospitalization

83
Q

Which health plan might apply 90% coinsurance to network providers and 70% coinsurance to non-network providers?

A

Preferred Provider Organization (PPO)

84
Q

All of the following would be considered benefits of insurance, Except:

The source of investments funds

Retention of the loss exposure by the insured

Payment for the cost of covered losses

Redemption of the financial uncertainty of the insured

A

Retention if the loss exposure risk by the insured

85
Q

Which of the following is not a feature of a major medical insurance policy?

Capitation

Deductible

Coinsurance

Maximum benefits limits

A

Capitation

86
Q

Assume that in each of the following examples the person is 65 years of age. Who has the greatest need for comprehensive long term- care insurance

A person with $500,000 of yearly income and $ 4 million in assets.

A person on Medi-cal

A person with $50,000 in yearly income and $130,000 in assets

A person with $5.000 in yearly and $7,000 in assets

A

A person with $50,000 in yearly income and $130,000 in assets

87
Q

When referring to an insurance contract, when must a representation be made?

A

Either at the time of or before policy insurance

88
Q

An individual is allowed to enroll in individual health insurance under the following circumstances EXCEPT

During the annual open enrollment period

Within 60 days of a qualifying event

At anytime for medi-cal

Wishing 39 days I’d being diagnosed with an illness

A

Within 30 days of being diagnosed with an illness

89
Q

If you were signed up with a preferred provider organizations (PPO) which if the following statements could you say about this program.

A

The PPO has agreed to pay for the service with a prearranged price depending on the type of service provided.

90
Q

What information can a party to a contract of insurance be allowed NOT to communicate according to California law

A

Information which the other party already knows

91
Q

How does a Medicare claim get started ?

A

Medical provider contact Medicare

92
Q

Which of the following describes a natural person employed to aid an agent or broker in transacting insurance other than life, disability or health insurance ?

A

An insurance solicitor

93
Q

An elimination period in a disability income policy serves the same function as:

A

The deductible in a medical expense policy

94
Q

Under Cal-Cobra all of the following would be considered qualifying events, EXCEPT

Divorce or legal separation from covered employee

Retirement

Loss of dependent status

Termination, regardless of conduct

A

Termination, regardless of conduct

95
Q

If a worker is now earning only $25k a year working part-time ($35k a year less than he earned a couple of years ago) and is earning less because of a disability, this disability would normally be called:

A

Partial

96
Q

The department of insurance has jurisdiction over all of the following EXCEPT:

HMOs

Workers compensation

PPO

Medicare Supplement Plans

A

HMO

97
Q

Hospital Indemnity Insurance provides money for all of the following EXCEPT:

Incidental expense

Out of pocket expense

Non medical expense

Medical expense

A

Medical Expense

98
Q

What is the most liberal definition of disability?

A

Own occupation

99
Q

Which is the most expensive LTC policy?

A

14 day elimination, 5 year benefit

100
Q

What is a typical disability provision for group disability policies?

A

Own- occupation for short period, then Any-Occupation

Accident & Health (1 decks)

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