Medicare - All chapters Flashcards

Question

Apparent Authority

Answer 1

appearance of, or assumption of authority. | may cause applicants to believe producer has authority

Answer 2

Actual authority the insurer gives the producer in the contract

Answer 3

Is not specifically stated in producer clinic --> Is authority the public may reasonably believe agent to have

Answer 4

All parties alive, sane, and authorized to contract

Answer 5

Time limit on contract... they cannot go on forever

Answer 6

Insurance company that issues an insurance policy and assumes the risk of potential losses suffered by the insured. Insurer pays consideration upon proof of loss

Answer 7

Life Insured who is responsible for filling out application

Answer 8

1. Person who pays the premium and has legal rights to the policy 2. Person required to be licensed under state to sell, solicit, or negotiate Insurance. (does not include a title Insurance agent)

Answer 9

Written contact effecting Insurance

Answer 10

payments made to the insurer to keep the policy in force

Answer 11

Provides comprehensive coverage by insuring against all direct loss (unless specifically excluded)

Answer 12

Uncertainty with respect to a loss. Possibility that a loss may happen - you are taking a risk

Answer 13

No; but, must investigate and remove any info that is not accurate, verifiable, or current.

Answer 14

Includes: Credit limit, current debt, late payments, open accounts, delinquencies Not included: Income of Individual

Answer 15

Metallic Plans 1. Bronze 2. Silver 3. Gold 4. Platinum

Answer 16

Mandatory acceptance and Insurance changes 1. accepts all applicants 2. covers specific list of conditions 3. charges the same rates regardless of pre-existing conditions or gender

Answer 17

Affordable Care Act (Patient Protection Act) Health Care Reform Law Intention: improve quality of Insurance, make affordable, expand by lowering cost to insureds, thus reducing uninsured rate

Answer 18

Home office = same state as domestic insurer

Answer 19

Home office = different state of Insurer | formed under laws of any part of US

Answer 20

Home office = another country | formed under laws of another country

Answer 21

Dishonest act. Intentional falsehood in order to deceive or take advantage of someone

Answer 22

assumed all parties entered into contract in good faith and have disclosed all relevant facts. where lack of good faith can be proven (fraudulent application --> Contract can be nullified).

Answer 23

Promise of what will be done Opposite of warranty is a breach or voided contract

Answer 24

Each party should have reasonable expectations that the other is activing without attempt to conceal or deceive.

Answer 25

State Law and Fair Credit Reporting Act

Answer 26

1. Avoidance: avoid / remove hazard 2. Retention: Doing nothing 3. Sharing: insurers share or pool loss 4. Reduction: reduce risk (alarm system) 5. Transfer: Shift to another party (purchasing Insurance)

Answer 27

an incorporated society, order, or supreme lodge formed and operated solely for it's members. can provide death, annuity, endowment benefits, but not benefits relating to property or casualty loses). Group of people getting Insurance

Answer 28

Admitted: Insurer entitled to transact insurance in a state Non-admitted: insurer or Insurance company not entitled to transact in a state Insurers must be authorized and licensed in the state

Answer 29

Inability to perform occupational functions. Person must first be "totally Disabled" prior to receiving partial or residual benefits. At work benefits are paid during the period of recover from total benefits.

Answer 30

Residual benefits pay for losses suffered by the insured AFTER recover. Usually, a portion reflecting the residual loss is paid (20% loss income). cannot make more on disability than they would working.

Answer 31

Provide a valued benefit - chosen by insured. When they are diagnosed with a covered illness. some cover more and some have restrictions, some iwll pay reoccurrence. (Cancer, stroke, heart attach, transplant, etc).

Answer 32

Legal principle that states that the insurer must honor it's representations when such representation has been relied on by the insured

Answer 33

Pays a "valued" (fixed) amount per day to insured while they are in hospital. - limited days - Pays regardless of other coverage - may pay "fixed" amount for other services - May include outline of coverage - Room and board - not less than 110.00 a day and for no less than 30 days

Answer 34

Some disabilities (loss of sight) are presumed to be total and permanent. Benefits are payable even if one can work.

Answer 35

1. Definite and definable 2. Accidental 3. Calculable 4. Create an economic Hardship 5. Insurance offered at reasonable cost 6. Must not be catastrophic 7. Law of large numbers

Answer 36

1. Allow agent to act and fulfil the terms of his/her contract 2. recognize all previsions of contract 3. compensate producer in timely manner 4. communicate with producer about new product development, marketing, etc.

Answer 37

Health Care Program in which an organization (HMO/PPO) acts as intermediary between insured and health care provider. Insurers decide to take an active role in containing the costs of their insured medical cost - most will also pay for routine cost. Goals: 1. arranging with providers to accept prearranged fees 2. Limit insured access to and choice of provider 3. encourages to use outpatient facilities rather than expensive in-patient facilities.

Answer 38

PCP: 1st person to see --> They send referral Open Panel HMO: Providers practice independently and see both HMO and non-HMO. IPA: Independent Practice Associates: List of providers supplied by HMO. Close Panel Plan: Providers practice solely for benefit of HMO Members Open-ended plan: Both open and closed can be open-ended. can use non-contracted doctor with reduce cost (ex. "snow Birds").

Answer 39

Form of care less restrictive than close-panel HMO, but more restrictive than PPO. Members must choose PCP from a network. PCP is Point of Service and determines the services required and provides referrals. Member can choose OON, but at a much higher cost to patient.

Answer 40

Sponsors and Health Care providers contract to treat plan members. small = Hospital and Doctor contract. Big = Network of providers. Member can choose any provider; higher benefits if they use a preferred provider. Provider Fee: PPO and Prov., reach agreement - will provide services for specific, contracted amount and in return; PPO refers patients to them. ("Fee for Service").

Answer 41

Provides pre-paid Health Insurance plans where members pay a flat, periodic pay ("copay"). Providers: same organization provides services and healthcare coverage. Membership in HMO entitles subscribers to use of plan-contracted physicians, hospitals, and clinics. Must obtain referral. coverage: Preventative care, covers all health care services and cop-payments (Kaiser).

Answer 42

Valued / Fixed payment Principle sum = 100% of Income for two "major" body parts Capital Sum = If death occurs within 365 days - considered the same accident Flexible; can be a rider or it's own plan A.D.& D. requires a revocable named beneficiary. A.D.& D. does not have a coinsurance deductible.

Answer 43

Controlled by [Policy Holders]. They vote for a board of directors who direct the affairs of the company. Mutual companies are participating companies, therefore issue [Par or non-par policies].

Answer 44

Graph / chart showing how many people are getting sick of what and at what age Shows the occurrence of sickness as a mortality table shows the incident of occurrence of death

Answer 45

% of loss of Income. Provides coverage for lost income resulting from a disability. Disability income will pay a % of your loss of income. Disability = loss of time and function (does not cover rehab or medical expenses).

Answer 46

Disability income policies pay a monthly income on "valued basis" ("fixed). This is pre-set & determined payment. Policies will pay %: 50%, 65%, 80% Percentage is set per month - example: will pay 65% of your normal income

Answer 47

Total time insurer will pay benefits Short Term: pay min of 26 weeks - up to 2 years Long Term: min of 2 years - up to age 65 or 70. The longer the benefit period, higher the premium

Answer 48

- Expense Incurred Basis: Payment to the insured is based off actual expenses incurred - Pre-paid: Specific Health benefits are provided to subscribers in return for period pre-payment. Paid by service organization. - Valued Basis: ("Indemnity"), Payment to insured is based off predetermined, specified amount - not related to expenses incurred

Answer 49

Provides coverage for medical expenses incurred by insurer for the following: 1. Acute care: Illness or Injury of abrupt onset and usually short duration 2. Chronic Care: Care for illness or injuries of long duration (I.E. Diabetes). Generally includes coverage for: Ambulance, in/out patient services, surgery, Dr.'s, Diagnostic Testing

Answer 50

Allows for % of paid premium to be refunded at end of pre-determined period (5 years, 10 years) if no claims were filed

Answer 51

Provides adjustment to disability income payments based on Consumer Price Index (CPI). Automatic. Must have been receiving DI Benefits for 1 year prior to the increase.

Answer 52

Allows for future increases to policy income benefits as wage increases. Need to provide proof of higher income.

Answer 53

Policies will limit or exclude benefits for certain adverse losses. Examples: - Resulting from war - Alcohol / Drug use - Suicide attempt - Undisclosed & pre-existing conditions - Felony / incarcerated - Pregnancy - Active duty military

Answer 54

Disability income can be integrated with workers comp, SSI, Employer Insurance Note: No Medicaid

Answer 55

Condition that increases the chance of a loss

Answer 56

first few days of a policy during which benefits are not payable. Do not apply to accidents. goals: reduce adverse selection

Answer 57

Policies that cover only specific disease. Benefits are valued and they vary. They can pay in one lump sum when diagnosed, or pay for specific expenses after the waiting period. Other policies may coordinate benefits with the cancer policy

Answer 58

Often a rider to an individual or group disability Insurance. Typically have low limits and exclusions. (1000.00 a year) to compensate or high incident of adverse selection. Typically cover 50% of dental charges.

Answer 59

May be a separate policy or rider to existing policy

Answer 60

Has manifested after the insured has been back to work at least 6 months (after 6m - considered a new disability) If returning within 6 months the insured would not be subject to a new elimination period

Answer 61

Payment to the insured is based on a pre-determined, specified amount, not related to actual expenses incurred

Answer 62

Health Benefits provided to subscribers in return for a period pre-payment. Provider is paid by the service organization (either as employer or contractor).

Answer 63

Reimbursement - Payment to the insured is based on the actual expenses incurred

Answer 64

1. Agents / Producers 2. Principle Principle employs or contracts with Producer

Answer 65

Provides a lump sum benefit which is used to "buy out" the business share of a disabled business partner

Answer 66

Provides benefits to pay certain business expenses when the insured is totally disabled. Allows business to continue for certain time period. Replacement income not paid to disabled insured.

Answer 67

Purchase through an employer - Sponsored disability plan Premium: paid by employer - Tax Deductible Benefits: Tax Deductible if employer pays 60% --> 60% taxable

Answer 68

Higher risk occupation = higher premium policies that exclude coverage for occupational injuries will have lower premiums

Answer 69

Application = offer Policy = acceptance (when offer is issued as requested) *if policy is issued other than requested then policy = offer and applicants acceptance would be premium payment

Answer 70

Stock insurer is an insured formed through sale of stock. Owned by a stock holder. Business to make profit for the stockholder. Can issue "Par Policies" (provide policy dividends), or "non-par policies" (do not provide policy dividends)

Answer 71

Failure to disclose a material face Concealment = misrepresentation

Answer 72

to restore a victim for loss in whole or part by payment, repair, or replacement

Answer 73

Statements in application Representation: Statements considered to be true (not guaranteed). If false; can be voided or denied Misrepresentation: Inaccurate statement, intentional or unintentional

Answer 74

Benefit paid reflecting an insured inability to perform some - but not all - job tasks. Usually 50% of benefits are payable. It usually follows total disability. The insured must be under a physician's care, and benefits are paid for up to 6 months.

Answer 75

Policy may require an insured to be under physician care in order to receive any benefits

Answer 76

cannot receive more in Benefits than they would be if they were working (uniform optional provision)

Answer 77

Should report every 6 months to the insurer

Answer 78

If employee becomes ineligible (after min of 3 months of work) --> they have 31 days to convert to an individual plan. During those 31 days --> Still covered by group policy if premium is paid. Based on Age. Dependents can still convert if employee was fired / death / divorce. 3 types: Basic Medical, Major Medical, & Supplemental Major Medical

Answer 79

Federal Law for employers with more than 20 employee's to offer continuation of group health benefits to employee's who voluntary/involuntary leave. Employer has 14 days to send & employee has 60 days to accept. Payment is due 45 days after acceptance. coverage up to 18 months --> May extend 11 months if qualifying disability. Dependents can have coverage up to 36 months if death, separation, loss of child or if employee goes on Medicare.

Answer 80

Federal Law. Cannot be denied coverage due to pre-existing condition. - May impose 12 month pre-existing condition waiting period on conditions treated within 6 months to previous enrollment. - must provide proof or prior "credible coverage" - Prior coverage will be credited to pre-existing condition waiting period - Continuous coverage; previous 63 days. ends on 64th day

Answer 81

1. Contributory: Employee contributes. 75% of the group must join to avoid adverse selection 2. Noncontributory: Employer pays 100% of premium. 100% of employee's must join. Easier to install and administer if 75% wants coverage for dependents, it must be offered.

Answer 82

first 30 days to join group plan through your works insurance otherwise you may need to wait until Annual Enrollment.

Answer 83

Time period before group Insurance is offered to it's employer

Answer 84

Not in favor of Insurance company. Tendency that high risk people want insurance more than low risk. Insuring = higher premium

Answer 85

Experience: Premiums are calculated using actual losses for group Community Premium: Premium calculated using losses in geographic area without adjustment for losses by group or individual Experience: Group/people Community: Geographic area

Answer 86

Homogeneous group: Written on group of people whose main purpose is other than that or obtaining Insurance underwriting is done on group as a whole rather than individually. Average ages, gender, and common risk determines premium

Answer 87

Must have HDHP, cannot have any other medical coverage or be dependent. Contributions: - If made by individual; Deductible - If made by employer; not income, deductible to employer. Limit set by IRS yearly. Can be made to tax deadline of following year. Withdrawal to pay qualified medical expenses that are not covered by HDHP = Tax Free. Nonqualified are subject to taxation and 20% penalty

Answer 88

High deductible and max OOP Expenses Deductible minimum and contribution limits are decided yearly by IRS

Answer 89

Employee sponsored. may be offered in conjunction with other employee provided benefits. must be used by qualifying employee - not used with other insurance employer contribution only - no limit - up to them Tax free. can "carry over" at discretion of employer

Answer 90

- Employee sponsored; "Cafeteria Plan" - Employer and employee contribute - Voluntary contributions not subject to income tax - unused contributions are forfeighted at end of year - Use it or lose it - use money towards qualified expenses (set/fixed amount).

Answer 91

Brought by employer/employee/consumers to get freedom in selection of health insurance plans and utilization of $$ allocated for health insurance Allows insured greater provider choice and flexibility in controlling cost, rather than relying on managed care plan. Insured pays for 1st Medical expenses in policy year (deductible or max OOP) --> CDHP used to cover and pay unreimbursed OOP

Answer 92

Covers large catastrophic losses. Policies are characterized by high limits - at least 1 million lifetime. or no limits with high deductibles (1000.00 or more)

Answer 93

Deductible amount that must be paid to insurer before insurer will cover. Considered flat or initial. Can be per occurrence or per year. Usually has family maximum. Co-Insurance: portion of medical bills the insured is obligated to pay (typically 80/20). Stop Loss: Max OOP protects insured. up to 12 months - 12th month starts on January 1st on policy anniversary date

Answer 94

Maximum benefit: Max an insurer will pay out in one year or over lifetime of a policy. Policies often contain inside limits (e.g., $ limit on particular procedure)

Answer 95

Under federal law, employer HMO must allow new employee's to enroll at least 1x a year. employers may offer a choice of group plans (PPO, HMO, Medical Expenses, etc.).

Answer 96

Designed to help defray the cost of extended care confinement by providing daily indemnity benefits (100, 150, 200) with benefit period that extend from 1-10 years. Includes group and supplemental Plans and individual policies. Individual: sold to individuals; individual health, gender, age, personal characteristics LTC policies are guaranteed renewable and require a minimum benefit period of one year (12 months). A waiver of premium rider is optional and would require additional premiums to be paid. group: Offered through employers - may be less expensive. All must comply with state regulations

Answer 97

Private Insurers offer Medicare supplement insurance policies. Medicare leaves a # of coverage gaps due to deductibles. Medicare Supplement Plans ("Medigap") is used to fill holes in coverage of Medicare part A and B. Insured must be covered under both A and B before they can get supplement plan

Answer 98

1. Accurately assess individuals need for Insurance, type, policy, and riders 2. Explain conditions and requirements 3. Solicit applications and accept premiums 4. Provide timely service

Answer 99

If insurer pays claim for losses suffered due to negligence of another - Insurer has the right to attempt to recoup the loss. The insurer can sue the negligent party on behalf of their insured, of the insurer can collect from the insured if he receives a settlement directly

Answer 100

Provides benefits for individuals who suffered job-related injuries or illness. *monopolistic: Insurance purchased from the state

Answer 101

Covered under Medical Expense Insurance

Answer 102

Group: One must be primary and one secondary. Secondary is used to pay left over expense from Primary. Concept of 100% indemnity. Duplication not allowed. If both parents commercial insurance - Parent DOB determines Primary. Individual: Prevents excess benefits. Insurer limits either total liability or for certain coverage

Answer 103

Refers to the frequency of premium payment. Weekly, Monthly, quarterly, annually. Automatic check withdrawals = Monthly

Answer 104

Beneficiary: Person(s) / Legal Entity to which proceeds are paid in the event of insureds death. Primary: 1st person (spouse). Must outlive insured. Contingent: child / 2nd choice. Receives if primary does not outlive the insured

Answer 105

Continuance of benefits required for kids who reach "limiting age" and are incapable of self-sustaining employment because of physical or mental handicap and are dependent on INS subscriber. may not cancel except for non-payment of premium. Insured has 31 days to provide insurer with proof of incapacity of dependent. Proof required only annually after 2 year period.

Answer 106

Owner has all legal rights to the policy. Owner may be other than insured, but must have insurable interest. Owners rights include: Pay Premium, assigning benefits to providers, changing beneficiaries, reinstating the policy. Owner rights are restricted if there is an irrevocable beneficiary.

Answer 107

Developed by NAID are found in all individual disability Insurance policies and benefit the insured

Answer 108

The Insurance contract, attached application and attached endorsements constitute the entire contact. The company cannot refer to other documents. an Insurer can insert provision that states that no policy changes are valid, unless approved by an executive officer of the insurer

Answer 109

(*incontestability clause). Within the first 2 years, an insurer can contest a policy for any material or misrepresentation. After 2 years, an insurer can contest a policy on the basis of fraudulent misrepresentation (identity) only.

Answer 110

Extends coverage past the due date. If the insured is injured during the grace period, the company pays benefits, less premium and interest. Based on how Premium is paid: (Policy can have longer grace periods) 7 days of grace if premium is paid weekly 10 days of grace if premium is paid monthly 31 days of grace if premium is paid over monthly

Answer 111

If the policy lapses because the insured fails to pay premiums, the policy can be reinstated by paying back premiums, interest, and proving insurability. if the insurer accepts the premium (with no requirement for a reinstatement application), reinstatement is approved. If the insurer does not respond within 45 days, it is deemed approved and fully reinstated. a reinstated policy does not cover illness in the first 10 days of reinstatement (waiting period) Premiums paid for reinstatement are applied to the period for which premiums have not been paid, but cannot be applied to any period more than 60 days prior to reinstatement.

Answer 112

Insured has 20 days (as soon as reasonably possible) to inform company of a loss

Answer 113

Insurer has 15 days to provide claim forms to Insured

Answer 114

Insured has 90 days from date of injury to provide proof of a loss. If the insured is incapacitated, there is an extension of up to 1 year from the date proof is otherwise required

Answer 115

Claims must be paid immediately to insured upon receipt of proof of loss. Payments for disability income may be made no less frequently than monthly (30 days)

Answer 116

If insurer fails to pay a claim, insured may file a lawsuit 60 days following proof of loss. Insured may not sue the insurer after 3 years from the date of proof of loss.

Answer 117

Allows Insurer to examine the insured as often as reasonably required at the insurer's expense. At death the insurer may perform an autopsy (unless prohibited by law)

Answer 118

If a Death Benefit is provided, the owner must be allowed to change the beneficiary (unless beneficiary is irrevocable).

Answer 119

Benefits are provided, as they would have been purchased with the premium paid, had age been stated correctly.

Answer 120

``` Insurance policies do not need to include these Provisions. However, if a policy contains a provision pertaining to one of these subjects, that provision must comply with the minimum standards as designed by the NAIC and State Laws. Previsions include: - Change of Occupation - Other Insurance with this Insurer - Insurance with other insurers - Relation of Insurance to Earnings - Unpaid Premiums - Cancellation - Conformity with state statues - Illegal Occupation ```

Answer 121

Portion of the Insurance contract in which the insurer agrees to indemnify the insured against certain losses, subject to limitations and exclusions

Answer 122

After the issuance and delivery of a policy, the insurer must provide time for the insured to read the full contract. If the insured returns the policy within 10 days , for any reason, the entire initial premium must be refunded within 30 days. the free look provision must be clearly stated on policy

Answer 123

Portion of the insurance contract which specifies the amount to be paid by the insured, in exchange for the insurer's promise to indemnify certain losses.

Answer 124

refers to the first few days of health policy where illness is not covered. This protects against adverse selection and preexisting conditions. In the case of an accident, there is no probationary period

Answer 125

a Time deductible that lowers premiums. Eliminates payments during the first 30, 60, 90, or 365 days after a disability

Answer 126

considered the same disability unless the insured has been back to work 6 months or more (Disability Income). *For recurrent disability - no new elimination period

Answer 127

Insurer waives premium if owner/insured becomes disabled. May have 6 month waiting period, after which premiums are refunded. Physician certification of disability and length of disability required. if this is not a provision, the insurer might offer it as a rider.

Answer 128

- Excess Charges: Insurer will only pay based on reasonable and customary charges for physicians in the same geographic area providing the same type of service. - Unnecessary Hospital Room Charges: Use of TV and Phones are generally excluded from coverage - Extended Care Facilities, home health care and Custodial: policies usually cover only rehab services; long term care policies cover extended care facilities - Hospice Benefits: for terminally ill patients, if included, may be limited - Dental, Vision, and Hearing Care: Many policies do not offer benefits for dental, vision, or hearing. Those that offer benefits limit benefits and may contain 50/50 coinsurance. - Work Related Injuries: Usually medical expenses from occupational injuries or sicknesses due to 'on the job' activities are covered by workers comp, when available. workers comp is primary. - Automobile injuries: Benefits are sometimes excluded or reduced when auto insurance coverage is available - Intentionally self -inflicted injuries - Elective and Cosmetic Surgery

Answer 129

Policy must list all services and expenses that are covered

Answer 130

Excludes coverage for a health condition that existed prior to purchasing the policy. Exclusion is temporary. After a stated period of time, the condition is covered.

Answer 131

in Health Insurance, a provision that the insured and the insurance company will share covered losses in agreed proportion. The preferred term is "percentage participation".

Answer 132

The amount of loss for which the insured is financially responsible before the insurer will provide coverage

Answer 133

A Specific dollar amount the policy owner must pay for a service

Answer 134

(A.K.A Prospective review, pre-cert review). This is a "Utilization Management" Technique. Insurers can require insureds to have some, expensive, medical procedures approved before they are undertaken. Approval is provided by the insurer, gatekeeper, or PCP. For emergencies, approval is required within 24 hours of service.

Answer 135

Insurer determines the amount payable for a service based on the usual, reasonable and customary charges in a given geographic area.

Answer 136

Most policies have policy limits. Limits help keep insurer losses down. Some limits are established through state or federal Legislation and all policies must comply. Limits can be: - Lifetime: E.g.; 1,000,000 limit of coverage on a major medical policy - Annual: e.g.; 1,500 per year limit on dental policy - Per Cause: e.g.; 30,000 per disability on a disability income policy

Answer 137

Allows insured to purchase additional benefits at a future date without additional evidence of insurability, such as a higher medical expense benefit limit.

Answer 138

Term rider added to a disability insurance policy. Rider pays an additional amount (higher benefit) for emergency room expense or at-home recovery

Answer 139

Policies must disclose renewability. Policies can only use what terms to comply with the stated provisions? (These provisions will not apply to group Insurance. 1. non-cancelable 2. Guaranteed Renewable 3. Conditionally renewable 4. Optionally renewable 5. Cancelable 6. Period of time for renewal

Answer 140

Insured has the right to keep the policy in force regardless of health until a specified age. Policy can only be cancelled for non-payment or premiums up to a specified age (50 or 65). Premiums stated in the policy cannot be increased.

Answer 141

Insured has the right to keep the policy in force without proof of Insurability. Policy can only be cancelled for non-payment of premiums up to a specified age (65 in a medical expense policy). Premiums may increase for entire class.

Answer 142

Insured has the right to renew the policy if certain conditions specified in the contract are met. Conditions may be related to age or employment. 45 day notice required to non-renew.

Answer 143

The Insurer has the right to non-renew the policy at the anniversary date or at the premium due date (by class) 45 day notice required to non-renew

Answer 144

Insurer may cancel the policy with 5 day notice. | Unused premium must be refunded.

Answer 145

Policy has no renewal option. No notice is required. Also known as "short term medical"

Answer 146

The Application contains general information about the applicant such as high or her person information, health information, family history, occupation, hobbies). 1. Applicant should be made aware of consequences of falsifying information on the application. 2. Changes: must be initialed by the applicant 3. Signatures: Application must be signed by the insured, owner, and producer 4. Premiums with the application: producer must give the applicant a receipt for premium 5. Warranty: Statement guaranteed to be true 6. Representation: Statement thought to be true, made by the applicant 7. concealment: is the intention to withhold information 8. Questions: on the application must be clear and precise

Answer 147

Determination by an insurer as to whether a person is insurable or not, based on certain requirements; e.g., health characteristics, family history, lab test results, etc. Insurers require persons desiring insurance to meet certain conditions. Producer must advise an applicant of sources of information. These are the Medical Information Bureau (MIB), the application, the producers report, the attending PCP report, medical exams, lab reports, results of questionnaires, and/or investigative consumer (Credit) reports.

Answer 148

Non-profit trade organization that maintains medical information on health insurance applicants to protect current policy holders from fraud and concealment. Info is only between Insurance companies. MIB Does not include actions taken by insurers nor amounts of INS requested.

Answer 149

- Written Notice to the applicant that the insurer may report health findings to the MIB - Permission by the applicant to disclose information to member companies - Upon written request, information contained n MIB files, must be disclosed to the applicant through the applicants Physician

Answer 150

Insurer must inform the applicant: - Consumer report may be required and the scope of that investigation - The name and Address of the investigating agency - If application was turned down because of the credit investigation - that he is able to obtain a copy of the report and have the opportunity to refute any information This insures confidentiality and helps in underwriting accuracy but does not guarantee it. Insurer has 30 days to notify the customer of denial of coverage if denial of coverage is based on report.

Answer 151

(A.K.A Inspection Report) may be a form of comprehensive credit report, triggered due to the face amount applied for, or due to an adverse credit score. Used to determine an applicants personal characteristics and possibly "moral hazards".

Answer 152

Producers receiving an initial premium at time of application must provide the applicant with: - Premium receipt identifying the insurer to whom the coverage is applied - Brief description of the coverage applied for - statement that the receipt does not indicate an acceptance of risk by the insurer (coverage is not binding or conditional).

Answer 153

Insurers often use age, gender, medical history, occupation, and other factors to determine rates. State laws usually restrict what specific criteria insurers can use.

Answer 154

- Application - Producer's Statement - Attending physician's Statement- sometimes an insurer requires a statement from the attending physician to explain a special medical condition - Medical examinations and/or lab tests - Credit Report and Inspection Report - Medical Information Bureau - Supplements to application

Answer 155

- Standard: "Average" risk - Risk is not abnormally high or low - Preferred: Lower risk; applicant has a lower than normal risk of disability. Premiums are comparatively low - Extra (substandard): High Risk; Applicant has a high potential of needing medical services. Premiums are comparatively high (rated policy) - Declined: Excessively high risk; risk of disability is so high that an insurer is unwilling to offer coverage. Often, insurers will exclude a certain peril or injury from coverage rather than decline.

Answer 156

If producer delivers, delivery must be timely. can be mailed or in person. Producer may not store the policy for the insured. States will often require additional documents to be delivered with the policy. Effective Date of Coverage: Coverage cannot begin until the correct initial premium has been paid and the risk (offer from applicant) is accepted by the insurer. Coverage typically begins upon policy issue or the 1st day of the following month

Answer 157

Producer should review the policy provisions, riders, exclusions, and ratings with the policy owner

Answer 158

Applications must solicit information about existing Accident and Health Insurance on the proposed insured. If the applicant indicates a desire to terminate an existing policy, the producer must provide a disclosure form, also known as "replacement form". Disclosure form explains possible consequences of terminating an existing policy. Producer must submit a copy of the disclosure form, signed by the applicant and the producer, with an application.

Answer 159

Contract of Insurance is a written instrument between an insured and an insurance company, specifying the coverage and consideration to be paid by the insured (premiums) and the insurer (settlement)

Answer 160

1. The names of the parties to the contract. The insurer's name shall be clearly shown in the policy 2. The subject of the INS, the Risk (Perils) Insured against, and conditions (if any) pertaining to the coverage 3. effective date of coverage and coverage period 4. Entire contract needs to consist of the policy provisions, application, any riders, and/or endorsements to the policy

Answer 161

When a 3rd party would suffer financially or emotionally upon loss or injury of the other party being insured. One has unlimited insurable interest in themselves

Answer 162

Statements guaranteed to be true (usually found in the insurance contract or policy)

Answer 163

Statements believed to be true (usually found in the insurance application)

Answer 164

1. Conditional: limits the rights provided by the contract. even when a loss is suffered, certain conditions must be met before the contract can be legally enforced. 2. Unilateral: Type of contract in which only one of the contracting parties is under an enforceable obligation 3. Adhesion: One party draws up the contract in it's entirety and presents it to the other party on a "take it or leave it" basis receiving party does not have the option of negotiating, revising, or deleting any part of the document.

Answer 165

Social Security = Government Insurance Program funded by Medicare Taxes and OASDI (Old Age Survivor Disability INS). Benefits include: Disability Income (SSDI), Retirement, Medicare, and Survivor Benefits.

Answer 166

Calculated based on a workers Average Indexed Monthly Earnings (AIME) and the Primary Insurance Amount (PIA). PIA is the amount equal to the workers full retirement benefits at the normal retirement age. Benefits payable to workers, their spouses, and children are expressed as a % of workers PIA. Worker must have paid into Social Security for 40 quarters to be fully insured or 6 of the last 13 quarters to be currently insured. If fully insured, he is eligible for all four benefits. if a person is currently insured, he is eligible for only survivor benefits and Medicare. One must be fully insured for retirement and Disability Income.

Answer 167

Social Security is a basic retirement income plan designed to supplement personal savings and employee retirement benefits. At the Normal Retirement Age (NRA), the Insured receives full benefits (100% of PIA). The NRA is increasing from age 65 (prior to 2003) to age 67 (after 2026). An Insured may begin receiving benefits as young as age 62 (less than 100% of PIA) and as old as 70 (more than 100% of PIA). Insured can continue to work while receiving Benefits but benefits can be reduced prior to NRA if earned income exceeds exempt income.

Answer 168

upon death, a surviving spouse (or minor child) receives a small lump sum ($225.00). Monthly Benefits can be received by: - Children until age 18 (19 if in school). - Disabled children of any age if they were disabled prior to their age 22. - Widow or widower that is either a minimum of age 60 or is caring for children under age 16.

Answer 169

Administered by Social Security Administration. - Qualification: To qualify for disability income benefits, a person must be "fully insured" (paid into SS for 40 quarters) and currently working. - Disability Defined: a disability has lasted, or is expected to last, one year or until death. It is a severe mental or physical condition that prevents a person for working. - Waiting Period: Person must be disable for 5 months before benefits will be paid. Payments begin the 6th full month after the date of the disability. - Benefits: Based on workers Average Indexed Monthly Earnings (AIME) and the PIA. If workers comp is paying, the amount of any workers comp payment is subtracted from the SSDI Benefit.

Answer 170

Administered by the centers for Medicare and Medicaid Services, Medicare is Federally Run and funded by payroll taxes

Answer 171

The Individual must be currently or fully insured and meet one of the following requirements: 1. be 65, or a dependent over the age of 65 (e.g., non working spouse) 2. Have been receiving SSDI for 2 years 3. Have permanent Kidney Failure 4. Amyotrophic Lateral Sclerosis (ALS, or Lou Gehrigs Disease) - Benefits Automatically begin upon receipt of SSDI Benefits.

Answer 172

Identifies payment for each type of case and fees allowed within a region

Answer 173

Medicare does not provide coverage outside of the U.S. or it's territories. On rare occasions there are exceptions to this (e.g., when a foreign hospital is closer than a US Hospital)

Answer 174

Medicare acts as the secondary insurance policy when a Medicare recipient is still working for a qualifying employer and is covered by a group insurance plan after age 65 (Coordination of Benefits).

Answer 175

- Part A: Hospital Insurance - Part B: Physician Care - Part C: Medicare Advantage - Part D: Prescription Drug Plans

Answer 176

Most people who qualify for social security or railroad retirement benefits automatically qualify for Medicare part A at age 65 (an enrollment form must be submitted to Medicare)

Answer 177

When you are first eligible for Medicare. This is a 7 month period that begins 3 months before age 65, includes the month turning age 65, and ends 3 months after the month the recipient turns age 65.

Answer 178

Between January 1st and March 31st each year. Coverage will begin July 1st.

Answer 179

There is no monthly premium for eligible individuals ("fully insured"). If an individual is not eligible for Medicare at age 65, they may pay premiums for Medicare Coverage.

Answer 180

All reasonable covered inpatient hospital expenses (after deductible) for 60 days. after 60 days (61-90), there is a coinsurance paid by patient. New benefit period begins when the patient has been out of the hospital for 60 days. Benefits for 1-60 or 61-90 days are restored with each new benefit period.

Answer 181

Hospice Care: Care and support for terminally ill and their family. Dr. must certify that the patient is expected to live 6 months or less. Skilled nursing Facility (SNF) Care: 100 days of medically necessary Post Hospital inpatient "convalescence" care (after deductible). first 20 days are covered in full after deductible, days 21-100 have coinsurance amount to be paid by the patient. must be: Medicare approved, 24 hour nurse, daily records, pursuant to law, skilled nursing care under supervision of physician. Post Hospital Home Health Care: E.g., RN's, Therapists. Patient must be "homebound".

Answer 182

Voluntary, supplementary medical plan. Part B covers physician services and medically necessary services and supplies, along with diabetes management and some other preventative services. Premiums: Government pays about 3/4 of the monthly premium. Recipient pays 1/4 of premium. Nonpayment of premium could result in higher premium. Recipient pays: Calendar year deductible, 20% of Medicare allowable charges, Excess over allowable charges. If a health care provider accepts assignment of the claim, patient is not required to pay.

Answer 183

Health Care Plan options (from Part A and B) approved by Medicare and offered through private companies to provide coverage for Medicare recipients. includes all services of Medicare A and B, plus supplemental coverage to fill caps. Plans resemble managed care plans which may include a 'network' of providers and specialists (HMO, POS, PPO, etc). Provides all medical care to Medicare recipients in exchange for the Medicare premium, plus additional cost. Plans may include supplemental payments to pay coinsurances and other non-covered expenses as well as Medicare approved expenses. These may also offer prescription drug coverage (through D). Plans usually eliminate need for Medicare Supplement Policy.

Answer 184

Medicare subsidizes private programs that offer drug assistance coverage to Medicare recipients. Enrollee's pay a monthly premium. Individuals who do not enroll in a Medicare Drug plan when first eligible, may have to pay a penalty for choosing to join later (higher monthly cost).

Answer 185

Medicaid is a welfare program enacted by the US congress in 1965. The Federal Government sets the minimum guidelines and the states may add to the coverage. Program ran by government. Provides Health Benefits for people of all ages that meet income and asset requirements.

Answer 186

No policy of individual insurance shall be delivered or issued for delivery in this state unless an outline of coverage is furnished. All policies must state: "Read your Policy carefully - this outline of coverage provides a very brief description of the important features of your policy".

Answer 187

- Statement identifying the applicable category of coverage with a description of principal benefits and coverage provided. - Statement of exceptions, reductions, and limitations - Statement of renewal provision, including any right by the insurer to change future premiums - Statement that the outline is a summary of the policy issued. Policy should be consulted to determine governing contractual provisions

Answer 188

Includes: Individual "Illness-triggered" fixed payments insurance, hospital confinement fixed payment insurance or other fixed payment insurance. Insurers must issue policies with a standard disclosure form. Must include: Insurer's name and address and Statement "Important info about coverage..." & "this coverage is not comprehensive health care insurance and will not cover the cost...". HDHP's: if you are covered under HDHP and have HSA, before you purchase this policy, you should check with your tax advisor to be sure you will continue to be eligible to have HSA. Replacement: Applications must have question to elicit information as to weather the insurance to be issued is intended to replace any other disability Insurance. If replacing policy, client must receive notice regarding replacement disclosure statement.

Answer 189

Regulates the selling of Medicare supplement insurance. States must comply with the Act but can regulate further. Sets minimum guidelines for all policies to provide uniformity and clarity to purchaser. Medicare Supplemental Insurance is sold through private insurers and must cover all the "basic Benefits" as stated in this regulation.

Answer 190

- Applicant: Person seeking to obtain an individual Medigap Policy for Insurance benefits - Certificate and Certificate form: Issued to employer sponsored Medigap Plan, indicating proof of coverage - Issuer: Insurance company, fraternal benefit society, health care service contractor, HMO, or any other entity delivering or issuing for delivery Medicare supplement policies or certificates. - Health Care Expense Costs: Expenses of a health maintenance organization or health care service contractor associated with the delivery of health care benefits to insureds (losses incurred). - Policy: contractual and unilateral agreement or contract issued by any issuer. Policy form is the form on which the policy is delivered or issued. - Premium: Amounts charged as consideration for a medicare supplement insurance policy and it's renewal. Earned Premium is the premium received by the issuer applied towards insurance coverage. Replacement: any transaction where new Medicare Supplement coverage is being purchased with knowledge that the existing plan will be replaced.

Answer 191

Private Insurers offer Medicare supplement insurance policies ("Medigap Insurance"). These Policies fill the coverage gaps in Medicare A and B. Must be eligible for Medicare, enrolled in part A and have purchased part B before they can buy Medicare Supplement policy

Answer 192

1. May not claim that the government approves a medigap policy 2. may not claim that other insurances (which are not medigap) contain medicare supplement benefits 3. Must give an outline of coverage prior to or at the time of application which clearly states type of coverage being offered.

Answer 193

Replacing Insurer must give a form of replacement notice. This gives pertinent information about replacement. Replacing insurer must waive preexisting conditions, waiting periods, probationary periods and elimination periods. Replacing insurer may only charge a Standard Rate (community-rated), with no evidence of insurability required.

Answer 194

No Medicare supplement insurer shall deny an "eligible person" issuance of Medigap coverage if applied for within 63 days of termination or prior coverage. an "Eligible" person is anyone who qualifies for Medicare and has been on a previous Medicare Advantage Plan (Part C), Group Health Plan, Employer Welfare plan or otherwise. The replacing insurer must waive preexisting conditions, waiting periods, probationary periods, and elimination periods

Answer 195

Insurers and producers are responsible to assure suitability in offering Medigap Insurance. Statements and Questions: 1. Do you have another Medicare supplement policy 2. Do you have any other health insurance coverage 3. If you are currently on Medicare part C., you do not need a medicare supplement plan 4. You may be eligible for benefits under Medicaid. If so, do not need Medigap coverage 5. Counseling Services may be available to assist in your purchase of Medicap (SHIBA - Statewide Health Insurance Benefit Advisors) Prohibited: twisting / pressure / advertising Regulations: must offer coverage A, file new policy forms with the commissioner within 30 days of change

Answer 196

Anytime a medicare supplement insurer requires a person's Medical history as a condition of insuring, the medical history must be completed by the applicant, relative, legal guardian, or PCP.

Answer 197

Insurers allow a 30 day return of policy refund or free look

Answer 198

Insurers must guarantee renewability except for non-payment of premium or material misrepresentation and may not use waivers to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions. Open Enrollment: Insurers cannot deny of limit coverage to individuals who apply for coverage within 6 months from their 65th Birthday Insurers must allow replacement of policies issued before 6/1/2010 to be replaced by plans post 2010 without evidence of insurability, including coverage A and "high deductible Plans"

Answer 199

There are 10 federally standardized plans available: A, B, C, D, F, G, K, L, M, and N; All Plans contain basic insurance and must pay: - Part A Coinsurance 61-90 of benefit period - Part A coinsurance days 91-150 of benefit period - Part A eligible covered hospitalization for 365 days during lifetime - Part A Hospice care coinsurance or copayment - Part B Coinsurance of 20% - First 3 pints of blood

Answer 200

Producers must take an initial 8 hour accredited LTCI course prior to the marketing or sale of LTC Insurance and receive an LTCI ''Line of Authority". Renewal consists or a 4 hour CE course every 2 years.

Answer 201

LTCI provides coverage for skilled care and personal care for individuals with prolonged physical illness, disability, or cognitive disorder. - policy provides lifetime coverage - policies provide daily benefits ($100, $120, or $150) on a valued or reimbursement basis. - Minimum benefit period is 1 year (WA min). Naturally longer benefit periods may be purchased (2 to 10 years, or unlimited) - Benefits are available after an elimination period (time deductible) of 30 days up to 1 year. Longer elimination periods allow for lower premiums.

Answer 202

1. Inability to do 3 ADL's (most insurers require 2) 2. Cognitive impairment, such as Alzheimers Disease 3. Physician Cert is required

Answer 203

Insurance includes any policy, contract, or rider that provides for payment of benefits based upon cognitive impairment or the loss of functional capacity. LTCI does not include provisions for Accelerated Death Benefits or specific limited policies.

Answer 204

Contract of long-term care insurance which provides asset protection under the Washington Long-term care partnership act.

Answer 205

Bathing, continence, dressing, eating, toileting, transferring (mobility).

Answer 206

Care of a non-medical nature which is essential to assist the individual in the activities of daily living. Generally this aids in meeting personal needs rather than medical needs

Answer 207

Problems with attention, affect, memory or other loss of intellectual capacity that requires supervision to help or protect the impaired person

Answer 208

Care requiring a licensed professional nurse, prescribed by a physician, is medically necessary and available on a 24 hour basis.

Answer 209

Provides medical services including nursing services, speech therapy, respiratory therapy, medical supplies, etc.

Answer 210

Provides non-medical services including homemaker services, assistance with ADL's, etc.

Answer 211

Services provided outside an institutional setting including home delivered nursing services or therapy, home and chore services, nutritional services, day care, respite care, etc. Policies shall provide benefits for these services at all levels of care, from skilled care to custodial or personal care

Answer 212

Care or services not specified in a policy but that may be provided if appropriate and agreed upon by the insurance company, the insured person and his or her physician. These benefits are then provided in lieu of normal contract benefits

Answer 213

Coordination of all aspects of long-term care. This includes assessment of needs, coordination of elements of a treatment plan, referrals, monitoring

Answer 214

Prioritizes the expectations and needs of the patient and family and prioritizes a program of treatment. Includes regular reevaluation of needs.

Answer 215

Daytime program for functionally impaired adults that provides a variety of services to those who are otherwise being cared for by family members.

Answer 216

Services to provide comfort and counseling for terminally ill patient and his/her family. Terminal care must be provided if the insured is expected to die within 6 months

Answer 217

Provides the caregiver and patient time away from one another for a short period of time. May provide a temporary care person to attend to the patient so the primary caregiver may take a break, holiday, or vacation.

Answer 218

``` To prevent spiraling increases in the cost of Health Care, no person shall participate in the submission, to a health care payer, or a claim for health care payment knowing the claim to be false (referred to as "deceptive"). Penalty for noncompliance: violation is considered a class C Felony. If a claim is paid, that is later found to be fraudulent, the insurer should seek to recover benefits paid. ```

Answer 219

any attempt to cause a health care payer to make a health care payment

Answer 220

Wholly or partially untrue or deceptive

Answer 221

Payment for health care services or the right under a contract, certificate, or policy of insurance to have a payment made by a health care payer for specific health care service

Answer 222

any insurance company or HMO authorized to provide health insurance in this state and insurer or other person responsible for paying for health care services

Answer 223

Application questions must be clear and precise. Producers should solicit more than simply a "yes" answer from the applicant. (Treatment received, medications, and results of tests, ailment, or treatment resolve).

Answer 224

The commissioner is authorized to set minimum standards for all types of disability insurance. Policies issued by insurers must comply. Categories include: - Basic Hospital expense, basic medical-surgical expense, hospital confinement coverage and major medical expense coverage. - Disability income protection coverage - Specific disease, specified accident or accident only coverage and limited benefit coverage - Medicare Supplemental Coverage

Answer 225

Each policy delivered or issued for deliver to any person in this state shall contain the provisions as specified in Washington code. An insurer may substitute these provisions with more favorable corresponding provisions, approved by the commissioner.

Answer 226

Health Care Services Contractors

Answer 227

a Health maintenance organization, and insurer, a health care service contractor, or other entity responsible for the payment of benefits or provisions of services under a group or individual contract

Answer 228

Consultative, diagnostic, and therapeutic services, as well as emergency and preventive care, inpatient hospital, outpatient and physician care, offered by a health maintenance organization

Answer 229

Member, subscriber, enrollee, beneficiary, or other person entitled to health care services under terms of a health maintenance agreement.

Answer 230

State department of social and health services (DSHS)

Answer 231

Person(s) who contact to receive health care services from a health care service contractor

Answer 232

contract for health care services available only to members of a specific group. The group contract may include coverage for dependents.

Answer 233

(A.K.A Closed Panel Plan): Health care professionals (which may be individual health professionals, clinics, or both) providing services exclusively for the HMO and it's participants

Answer 234

association of health professionals in private practice who practice independently, yet contract with the HMO to provide comprehensive health care services to participants, on a prepaid, fee-for-service or capitation basis. Also known as an "open Panel Plan" or independent practice association (IPA)

Answer 235

A "Carrier" which has been declared insolvent and is placed under an order of liquidation by a competent judicial court

Answer 236

an Insurer may not engage in any insurance transaction for life or disability on individuals in this state under a group policy to a policyholder outside this state when it is not clear or is misleading and does not include all terms and conditions required by Washington State statutes.

Answer 237

Means and includes medical, surgical, dental, chiro, hospital, optometric, podiatric, pharma, ambulance, custodial, mental health, and other therapeutic services

Answer 238

An agreement for services between a health maintenance organization and enrolled participants

Answer 239

Any charted organization that provides comprehensive health care services to enrolled participants. Prepayment may be on a group practice per capita basis or individual practice plan. Participants are responsible for copayments and/or deductibles

Answer 240

Health care practitioners who are regulated by the state of Washington

Answer 241

Contract for Health Care Services issued to and covering an individual (and dependents). Underwriting is on individuals covered and cost (premium) is wholly paid by the insured.

Answer 242

Procedure for investigation of consumer grievances in a timely manner aimed at mutual agreement for settlement according to procedures approved by the commissioner, and which may include arbitration procedures

Answer 243

Any provider who has contracted with an HCSC to accept an agreed upon payment from the HCSC for any health care services rendered to an "enrolled participant".

Answer 244

Any health professional, hospital, or other institution, organization, or person that furnishes health care services and is licensed to furnish such services.

Answer 245

Means a discrete program of chemical dependency treatment provided by a treatment program certified by the department of social and health services

Answer 246

Illness characterized by a dependency on a controllable substance or alcoholic beverage resulting in the user losing self control

Answer 247

person certified as a chemical dependency professional by the washington State Department of health

Answer 248

Includes deductibles, copayments, coinsurnace, and out of pocket expenses.

Answer 249

Medical condition manifesting itself by acute symptoms of sufficient severity, including sever pain, such that a prudent layperson who possesses an average knowledge of health and medicine. Could reasonably expect the absence of immediate medical attention to result in a condition placing eh health of the individual in jeopardy, serious impairment to bodily functions, or dysfunction of any bodily organ.

Answer 250

with respect to chemical dependency coverage is defined by the American Society of Addiction Medicine patient placement criteria.

Answer 251

Includes limits on the frequency of treatment, number of visits, days of coverage, waiting periods, or other similar limits on the scope or duration of treatment

Answer 252

an Illness characterized by a dependency on a controllable substance or alcoholic beverage resulting in the user losing self-control. Group contracts, including group HMO contracts, must provide a minimum dollar amount of coverage over a 24 month period in an approved treatment facility or program.

Answer 253

1. Any group contract providing coverage for chemical dependency benefits must define "chemical dependency" consistent with definitions in the code. 2. Must include payment for reasonable charges for any medically necessary treatment and supporting service rendered to an enrollee by an approved treatment program 3. Cost sharing amounts for chemical dependency services may be no more than the cost sharing amounts for medical and surgical services otherwise provided under the health benefit plan. 4. Lifetime limits must apply to chemical dependency benefits in the same manner as medical and surgical benefits 5. Treatment limitation for chemical dependency services is allowed only if the same limitation or requirement is imposed on coverage for medical and surgical services. benefits for treatment and services rendered may no the denied solely because treatment was interrupted or not completed. 6. Medically necessary detoxification must be covered as an emergency medical condition.

Answer 254

Employee or covered dependent that becomes ineligible for group coverage, after a minimum of 3 months coverage, has 31 days to convert the group policy to an individual policy. Group HMO's must offer the plan holder the right to continue the group benefits for a period of time at an agreed upon rate. After which, conversion must be offered.

Answer 255

Health Care Providers that provide coverage for dependent children of all participant shall provide coverage for newborns from birth. If additional premium is required, notification of birth must be within 60 days. Adoption is considered birth and treated the same as newborn.

Answer 256

Individual and group health care service plan contracts that are not "grandfathered" and that provide coverage for a subscribers child must offer the option of covering any child under the age of 26, unless child is eligible to enroll in an eligible health plan sponsored by the child's employer. Grandfathered: plans in place before 3/23/2010, when the ACA was signed into law.

Answer 257

WA Basic Health plan means: Administrator of the WA State Health Care Authority

Answer 258

Rating method used to establish the premium for health plans according to actuarial differences in geographic region, age, family size, and utilization of routine care

Answer 259

To Improve the health of low-income children and adults by expanding access to basic health care and by reducing tobacco-related and other illnesses that disproportionately affect low-income persons

Answer 260

To provide or make more readily available and affordable, necessary, facilitated basic health care services to working persons and others who lack coverage.

Answer 261

Employer or group sponsor may pay the health plan cost on behalf of an eligible enrollee, with prior approval of the administrator and upon prior arrangement with an enrollee. the administrator receives an IRS Tax credit on eligible enrollees.

Answer 262

means the schedule of covered health services, including the description of how benefits are administered, that are required to be delivered to an enrollee under the basic health plan. The plan will be reviewed and revised from time to time.

Answer 263

any health benefit plan that provides benefits for hospital inpatient and outpatient physician services and prescription drugs prescribed in conjunction with these services.

Answer 264

Review and prior approval by the administrator that a procedure and/or hospital stay is medically necessary and appropriate according to the auspices of the applicable health benefit plan.

Answer 265

Utilization review conducted during a patients extended hospital stay or course of treatment to assure continued appropriateness for subsidized funding.

Answer 266

Person covered by a health plan including a subscriber, policyholder, beneficiary of a group plan or individual.

Answer 267

Enrollee's Legal spouse and qualified unmarried dependent children

Answer 268

Department of Social and Health Services

Answer 269

covered health care services medically necessary to evaluate and treat an emergency medical condition which is a symptom or condition that requires immediate medical attention.

Answer 270

Enrollee's copayments, coinsurance, or deductibles

Answer 271

Any policy, contract, or agreement offered by a health carrier to provide, arrange, reimburse, or pay for health care services except for: - Long term Care Insurance - Medicare supplemental health insurance - Limited Health care services and plans deemed by the insurance commissioner to have a short-term limited purpose (short term medical) - Disability Income and Accident only Coverage - Coverage incidental to a property/casualty insurance policy (i.e, PIP, or Homeowners med. Pay) - Workers compensation coverage - Employer-sponsored self-funded health plans - Dental only and vision only coverage

Answer 272

The prospective assessment of the need and appropriateness of providing health care services to an enrollee or group of enrollee's.

Answer 273

Regimented activity consistent with department of health guidelines for the purpose of improving enrollee health status and reducing health service cost.

Answer 274

Every health provider providing coverage for maternity services must permit the attending provider, in consultation with the mother, to make decisions on the length of the inpatient stay. Decisions are not to be made based on contracts provisions or agreements between providers, hospitals, and insurers. Decisions must be based on accepted medical practice.

Answer 275

- must provide services for inpatient, post-delivery care to a mother and her newly born child, which is ordered by the attending provider, in consultation with the mother after delivery. - Type and Location of follow-up care upon discharge, must be made by attending provider and in consultation with the mother. - Covered eligible services may not be denied for follow-up care, including in-person care, as ordered by attending provider in consultation with the mother. Coverage for the newly born child must be no less than the coverage of the child's mother and for no less than 3 weeks.

Answer 276

Establishes a process for the fair consideration of disputes relating to decisions by carriers. Enrollee's may seek review by a certified independent review organization or decision made. No later than the third business day after the date the carrier receives a request for review, carriers must provide the certified independent review organization a copy of: - Medical records of the enrollee - Documents used by the carrier in making determination - documentation and written information submitted to the carrier in support of the appeal - list of each physician or health care provider who has provided care to the enrollee. Enrollee's must have at least 5 business days to submit to the independent review organization information needed.

Answer 277

- may not deny coverage of child for any reason - Urgent and immediate service must still be covered even if child doesn't reside in service area - INS offering broader coverage will provide coverage to any child otherwise covered that does not reside in service area - INS must continue coverage for eligible children in cases of divorce. Where a parent is required to provide health coverage for a child, and parent is eligible for family health coverage, provider of benefits must not disenroll an eligible child. - Coverage providers assigned Medicaid recipients may not impose requirements on the health care authority that are different from requirements applicable to an agent of any individual so covered. - Where current health coverage is available through a noncustodial parent, the plan sponsor will provide info to the custodial parent for the child to obtain health benefits. Allowing the custodial parent to submit claims for covered services without approval of noncustodial parent.

Answer 278

- Scope of Code: All INS and INS Transactions in this state, or affecting subjects located within this state, are governed by this code - Public Interest: The business of INS is one affected by the public interest, requiring that all persons be actuated by good faith, abstain from deception, and practice honesty and equity in all INS matters. - Insurance: Contract whereby one undertakes to indemnify another or pay a specified amount upon determinable contingencies. - Insurer: used in this code includes every person engaged in the business of making contracts of ISN. - Insurance Transaction: Includes; solicitation, negations, execution of INS contract, transaction of matters subsequent to contract, insuring.

Answer 279

- Person: any individual, company, insurer, association, organization, reciprocal, or interinsurance exchange, partnership, business trust, or corporation - Penalties: guilty of a gross misdemeanor and be fined not less than $10 or more that $1000, or imprisoned for no more than 364 days. - INS Commissioner (IC): Elected for 4 years

Answer 280

- IC has authority expressly conferred upon him or implied from provisions of code - IC must execute duties and must enforce provisions of code - IC may: make reasonable rules for effectuating this code, which first must be filed for public investigation, conduct investigations to determine if someone has violated, conduct examinations, investigations, and hearings - When governor proclaims state of emergency, the IC may issue an order that addresses any of the following: Reporting requirements for claims, grace periods for payments, temporary postponement of cancellations and nonrenewal, and medical coverage to ensure access to care. - an order by the IC under subsection (4) of this section may remain effective for not more than 60 days. - IC may adopt rules that establish general criteria for orders issued under subsection (4) and may not adopt emergency rules applicable to a specific proclamation of a state of emergency by the governor.

Answer 281

- IC may prosecute an action in any court of competent jurisdiction - IC shall certify the facts of the violation to the public prosecutor of jurisdiction - The IC may: issue a cease and desist order, or bring an action any court of competent jurisdiction to enjoin the person from continuing the violation. - Attorney General and several prosecuting attorneys throughout the state shall prosecute or defend all proceedings brought pursuant to the provisions of this code when requested by the IC. - IC may delegate authority -

Answer 282

- IC Shall examine each insurer holding a certificate at least every 5 years - IC shall examine rating organizations and examining bureaus at least every 5 years - IC may accept an audit of out of state insurers from their state of domicile or port-of-entry state - iC may examine insurance producers, adjusters or title insurance agents of a person holding shares or proxies of domestic insurers for the purpose of control.

Answer 283

Most policies must be filed at least 30 days before use with the IC. If no action has been taken by the IC, the policy will be deemed approved.

Answer 284

IC may place on probation, suspend, revoke, or refuse to issue or renew a license for: Violating insurance laws, providing misleading info, misrepresentation, cheating, etc. Business license may be revoked if the managers don't report violations. the IC may enforce the law even if a license has been lapsed by operation of law. To revoke or suspend a license, the IC must give 15 day written notice. Suspension may not exceed 12 months. Fines shall not exceed 1,000 per violation and paid within 30 days. Hearing: producer may ask for a hearing to contest the revocation or suspension within 90 days of the notice. this must be done by written notice to the IC. IC must hold hearing within 30 days.

Answer 285

Unlicensed activities are a Class B Felony - a fine up to $20,000 and 10 years imprisonment, in addition to any civil penalty imposed. Civil penalties - IC may issue a cease and desist order, suspend or revoke a producers license, and/or impose a fine of up to $25,000 per violation.

Answer 286

Insurance is a contract whereby one undertakes to indemnify another or pay a specified amount upon determinable contingencies

Answer 287

Domestic mutual insurer is owned and operated in the interest of it's members. Each member shall have one vote in the election of directors and may receive dividends from surplus and net earnings of it's business. No dividend may be contingent upon paying a renewal premium. Policies are called participating (par) policies.

Answer 288

INS transaction includes any: Solicitation, negotiations, execution of an insurance contract, transaction of matters subsequent to execution of the contract and arising out of it, insuring

Answer 289

Authorized insurers must have a certificate of authority stating: INS name, location on principal office, kinds of INS authorized to transact in this state. Settlement of claims by an unauthorized insurer is not considered an insurance transaction. Any unauthorized insurer transacting business in WA submits itself to the courts of WA. Placing business with an unauthorized insurer may result in a fine up to $25,000 per violation. Surplus line coverage is used for ins that cannot be procured from an authorized insurer. - must be procured through a surplus lines brother - a diligent effort must be made to ascertain coverage is not available - cannot be procured just to get a low premium - filing with the IC within 30 days of procuring coverage attesting these facts must be made.

Answer 290

For life and disability contracts: - Covers insolvency of member insurers - insureds are covered by only one state association - Contract interest rates will be calculated for the past 4 years before insolvency as the average for that time using Moody's corporate bond yield average minus 2 points. After insolvency the rate will be 3 points less the moody's corporate bond yield. - limit for one life, surrender value, major medical, disability income, annuity is $500,000. Group contracts covered up to $5,000,000 - Not covered HMO's, health care service contractor, fraternal, mandatory state pooling plan Purpose is to avoid delay and loss to claimants and policyholders because of insurer insolvency. Covers insurers authorized to transact in this state at the inception of a policy or at the time of claim. All insurers must remain members of the association as a condition to transact insurance. Powers shall be exercised through a board of directors.

Answer 291

- Producer: May act as agent / broker. Producer must be appointed by those insurers. (appt notice sent by the insurer to the IC stating the producer represents them). To act as broker, they must have a bond. Bond is greater of $2,500 or 5% of the brokered premium the previous year (Important: Agents represent insurers and brokers represent the applicant or insured) - Life Producers: selling variable products must be FINRA (Securities licensed) registered

Answer 292

Temporary license may be issued by the IC because of death or disability of a producer not to exceed 180 days to: - Surviving spouse or court appointed personal rep - person of a business entity licensed as a producer - Designee of a licensed producer entering active military service - Others where the IC deems public interest will best be served (Temporary Licensee may be limited by IC, temporary licensee may be required to have a suitable sponsor, or end upon disposal of business

Answer 293

Non-resident license may be issued to producers in good standing in their home state, for the same lines of insurance, if that state reciprocates with WA. No finger print necessary IF required by the resident state and no test is required. Continuing Education is also reciprocal. the IC must be appointed by the producer to receive service of legal process issued against producer. Exemptions: - Insurer - Officer, Director, or employee of an insurer not receiving commissions - Employer providing insurance benefits and not compensated in any manner - Person advertising in this state as part of a multiple state ad, who does not sell in WA. - Person forwarding group credit insurance applications who receive no commission.

Answer 294

An appt is authorization given by an insurer or agent to a producer, granting permission to represent the company/agency in transacting insurance business on their behalf. Appointments - are required from each insurer a producer represents. INS producers must be authorized to transact at least one line of authority within the authority of the insurer or the business entity (initial appt). Unlicensed will be denied.

Answer 295

1. refusal / nonrenewable 2. Suspension / Revocation: Suspension may be for a max of 12 months. Producer is informed, in advance of start and end date. License shall be suspended for non-compliance DSHS order. Revocation of a producers license may be permanent. Commissioner must provider a 15 day written notice (3 day notice if for public safety prior to. 3. Probation: Commissioner may probate a suspension or revocation of a license under reasonable terms determined by commissioner. May need to report, limit practice, or continue education. 4. Fines: IC may levy a civil penalty or any combination of action or violations of the code.

Answer 296

- Initial and reinstated individual licenses are valid from their date of issuance until the end of the licensee's next birth month plus one year - after initial renewal, licenses are valid for 2 years and must be renewed prior to the end of the birth month of the licensee - Renewal filed with the IC before expiration, allow a producer to continue to act under his license - Licensees must inform the IC of an address or email change within 30 days. - Business entity's license is valid for two years from issuance

Answer 297

Resident producers in life, disability, personal lines, property, casualty, or variable insurance must meet continuing education requirements. (exempt: adjusters and limited lines). Requirements: - 24 credit hour of which 3 hours must be in ethics. Producers needed to complete courses required to sell specific insurance plans (E.g.; annuities and LTC). - Course completion within 24 months of license expiry - no hours may be carried over for next renewal - Waivers may be granted for Medical / Military

Answer 298

Late renewal fee consists of the renewal license fee and surcharge: 50% surcharge after license expiry date for first 30 days late; 100% after 30 days up to 60 days late; after 60 days to 12 months late, 200% and license reinstatement

Answer 299

Any insurance producer having administrative action taken against them in another jurisdiction, or by another governmental agency in this state, shall report it to the commissioner within thirty days

Answer 300

DRLP must be given the necessary authority and info by the business entity that reasonably assures that the DRLP can cause or influence the entity's compliance with all applicable ins laws, rules, or both of state.

Answer 301

Public Interest: Business of INS is one affected by the public interest, requiring that all persons be actuated by good faith, abstain from deception, and practice honesty and equity in all ins matters.

Answer 302

Insurers and their reps must act in good faith and in a timely manner during claims process. - Insurers must respond to claim within 10 working days (15 for group) - Insurers must respond to an inquiry by IC within 15 working days - insurers must complete investigation of a claim within 30 days after notification (unless cannot be completed in that time). - Insurers must within 15 days of proof of loss, notify first party claimants of denial or acceptance.

Answer 303

It's unfair method of competition and an unfair practice for any insurer to engage in any insurance transaction, regarding life insurance, annuities, or disability ins coverage. It is further defined to be an unfair practice for any insurer marketing group insurance coverage in this state to fail to comply with the state requirements.

Answer 304

- The relationship of a producer appointed by an insurer shall be that of insurer and agent - Producer may receive commission from the insurer and a fee paid by the insured - if both commission and fee, the producer may reimburse part of the fee - if fee is charged for each policy, then the fee, commission, offsets, or future bonus's must be disclosed in writing, signed by producer and insured and kept on file for 5 years

Answer 305

Violation of the statutes for insurers or producers to offer, promise, discount premium, or give money to induce a perspective insured to buy a policy

Answer 306

No insured personal shall accept such a rebate as described above, which is not specified in the insurance contract

Answer 307

Insurer/producer/title agent may not offer as an inducement to the purchase of INS or in connection with any insurance transaction.

Answer 308

Commingling: combining the customer's money (premium) with the producers funds. Violation is misdemeanor. *charging too much and keeping excess / charging premiums not needed

Answer 309

No person shall by misrepresentations or misleading comparisons, induce or tend to induce any insured to laps, terminate, forfeit, surrender, retain, or convert any INS policy

Answer 310

Intentionally making false or misleading statement. Guilty of gross misdemeanor and loss of license

Answer 311

Includes publishing or disseminating false or maliciously critical info designed to insure an insurer

Answer 312

Unfair when based on sex, marital status, sexual orientation, handicap unless bona fide statistical differences in risk have been substantiated

Answer 313

Any representative of an Insurer who receives a payment or premium for personal insurance shall issue a receipt no later than the next business day Failure to issue proper receipts: Any representative of an insurer who receives a payment or premium for personal insurance (personal lines) shall issue a receipt no later than the next business day. The receipt need not be independent of the application. It must be dated, identify the insurer and insured, include the amount paid, with a brief description of the insurance it's applied to.

Answer 314

the IC may define other acts to be unfair and promulgate by regulation restrictions, effective no earlier than 30 days later. the IC may order a person to cease and desist and fine $1,000 per violation thereafter.

Answer 315

- don't make misleading statements or advertisements - insurer must have it's full name and home office location in advertisement - no person who is not insurer can claim they are - Ads showing financial conditions of the insurer must correspond to the state - no ads may reference in any fashion the WA INS Guaranty Assn. Act No person shall knowingly make or publish any misleading statements or advertisements relative to the business of insurance or any person engaged therein. An insurer must have its full name and home office location (domicile) in an advertisement. No person who is not an insurer may infer it is. Ads showing financial conditions of the insurer must correspond to the last filing with the state. No ads may reference in any fashion the WA Insurance Guaranty Assn. Act.

Answer 316

Policies must be delivered to the policyholder within a reasonable time after issuance.

Answer 317

Producers must report the exact consideration charged as premium to the insurer and that premium shall be shown in the contract.

Answer 318

All funds received by a producer must be segregated and maintained in a separate account. No agency or personal funds may be combined with premiums in this account (commingled).

Answer 319

must respond in writing promptly to an IC inquiry. Responses must be within 15 business days of inquiry

Answer 320

No entity may pay any person for selling, soliciting, or negotiating insurance unless that person is licensed. Renewals may be paid if the person was licensed at time of sale.

Answer 321

the IC may permit a reduced fee for other services so that an overall charge to an insured is reasonable

Answer 322

Mutual insurers sell participating policies (par) and if dividends are to be paid, they go to the policyholders.

Answer 323

PART A: HOSPITAL INSURANCE Covers reasonable and covered inpatient hospital expenses. 1 - 60 days A benefit period deductible (Set by CMS) 61 - 90 days A daily coinsurance (usually 1/4 of the benefit period deductible) 91 -150 days A daily coinsurance (usually 1/2 of the benefit period deductible) (Reserve benefit) The benefits for 1 to 60 days and 61 to 90 days are restored each benefit period. Deductibles are also restored. The 91 to 150 day benefit is a once in a lifetime benefit called a reserve benefit.

Answer 324

Guaranty Association Purpose is to avoid delay and loss to claimants and policyholders because of insurer insolvency. Covers insurers authorized to transact in this state at the inception of a policy or at the time of claim. All insurers must remain members of the association as a condition to transact insurance. Powers shall be exercised through a board of directors.