Nj Accident And Health Flashcards
Adam is an insured under a Major Medical policy written through an HMO. When he submits a claim, the policy would require him to do all of the following EXCEPT
Pay the medical vendor and then submit a claim for reimbursement
Olivia owns a Disability Income policy with a Change of Occupation provision that will pay a $4,000 per month benefit. When she changes from a high-riskoccupation to a low-risk occupation, spation, she fails to tell her insurance company. How will Olivia’s company respond to a covered loss six months later?
Pay $4000 per month and refund the unearned premium.
Which is considered a cost containment in health insurance?
Utilization Management
All of the following are requirements to qualify for social security disability benefits Except when
Unable to work in the occupation in which the worker was trained or educated.
Whitch statement about Cobra is False?
An insured person who quits their job forfeits their rights under cobra.
A preexisting condition under a Medicare supplement policy must have occurred and/or been treated within how many months of the effective date of the MSP?
6
Under a family Medical Expense policy without maternity benefits, when are newborns covered?
The moment of birth
An employee and his spouse are covered under Group Major Medical at XYZ Industries, and the spouse loses coverage following a divorce. How many months canthe spouse continue coverage under COBRA?
36
What happens when a major medical policy is reinstated on September 10th?
Accident coverage begins on September 10th, and sickness coverage begins on September 20.
Which health insurance benefits are taxable?
Benefits from an employer paid group disability income policy
The Additional Monthly Benefit Rider exists to pay income during a period of disability while the insured is waiting for benefits to be paid or denied by
Social security
A health maintenance organization (HMO) differs from a traditional insurer in that an HMO
Emphasizes preventive medicine
The life insurance policy will not be truly effective until all of the following except
The producer has explained the policy to the client
The agreement at which a child is no longer eligible for coverage under a parent’s medical expense policy is known as
Iimiting age
What does the health insurance time limit on certain defenses/incontestable clause state?
The company can only challenge the accuracy of statements made in an application for health insurance for up to 2 years.
Which health rider would not increase the cost of the policy?
Exclusion Rider
What does coinsurance mean?
The insurer and the insured share expenses over the deductible.
What does a life annuity protect against?
Outliving income
Which of the following is the most common method to supplement Medicare coverage?
Coverage offered by private insurers
Which is a source of underwriting information?
Attending physicians’ reports
If an insurance company obtains an investigative consumer report on a prospective insured, it MUST inform the prospect that it is permitted to do so under which of the following Federal laws?
The fair credit reporting Act
The uniform individual health policy provisions law requires a policy owner to wait at least how many days from submitting a claim before legal action?
60
Which level of long-term care must be provided occasionally by a skilled practitioner following doctor’s orders?
Intermediate care
In a Preferred Provider Organization (PPO), what is the primary financial benefit for an insured member to use only the services of a listed health care provider?
Lower cost sharing expenses
What is the primary qualifier for Medicaid?
Financial need
What is a conditional receipt intended to do?
Speed up coverage
Which is a cost containment feature stressed by HMOs?
Use of primary care physicians as gatekeepers.
What is an MBI report?
Medical information on an applicant for assessing life or health insurance risk.
Which of the following requires the claim information to be submitted to the insurer prior to treatment to determine whether the treatment is covered and how much the insured’s plan will pay?
Pre-certification Provision
All of the following are required signatures on a life insurance application except?
The minor in a juvenile policy
Which type of receipt makes the insurer liable for the risk from the date of application, regardless of the applicant’s insurability?
Binding receipt
Which major medical policy is triggered by one disease?
Dread Disease policy
Which policies pay benefits for employee occupational injuries and illnesses?
Workers Comp and individual Disability income
Hipaa applies to groups of how many participants?
2
What is Not a reason why someone may receive a rated or substandard rating on their policy?
Age
Joe has A Major Medical policy with a $500 deductible and 80/20 coinsurance. He suffers a covered kiss of $2500. How much does the insurance company pay?
$1600
What is the purpose of an elimination period in a health policy?
To serve as a time-based deductible
What does the legal action provision of an individual health policy state?
Insureds must wait 60 days after filing proof of loss to initiate a lawsuit and must act within 3 years.
Which is not an activity of daily living as defined by a long term care policy?
Driving
When can the premiums of an individually owned health insurance policy be deducted from the individual’s income tax?
When the taxpayer’s unreimbursed medical expenses exceed 7.5% of adjusted gross income during a taxable year
Which does nothing to reduce adverse selection?
Elimination Periods
What are Disability income benefits based on?
Earned income
Which regulations were established by the federal trade commission and federal communications commission to Protect Consumers?
National Do Not Call List
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Which is the minimum number of the 6 Activities of Daily Living (ADL) an insured must be incapable of performing in order to trigger the benefits of a Long TermCare Policy?
2
Offer, acceptance, and consideration are necessary elements of…
A contract.
Which part of Medicare is also known as Medicare Advantage?
Part C
Since only the insurance company can make a legally enforceable promise, what type of contract is this considered to be?
Unilateral Contract
A producer takes a prepaid application on a Major Medical policy from a cona couple on October 1st. They sail through underwriting, and a policy with an effective date of October 15 arrives in the producer’s office on October 17. What should the producer do when he delivers the policy?
Review the policy benefits, exclusions, and riders.
A long-term care policy covers which of the following?
Respite Care
Under the Uniform Individual Health Insurance Policy Provisions law, how many days does the company have to provide you with Proof of Loss forms following receipt of your Notice of Claim?
15
Which is not established under the Patient Protection and affordable care act (ACA)?
High deductible health plans (HDHP)
Susan has a Disability Income policy which has a $1.000 monthly benefit limit. On the third month of a covered disability, she receives her first check for $925, and all subsequent checks are for $925 as well. What is the most likely reason for this discrepancy?
The change of occupation provision
If an Accidental Death and Dismemberment (AD&D) policy pays for the loss of one limb, what is the amount paid?
The Capital Sum
All of the following are characteristics of an HMO EXCEPT?
Easy access to specialists.
Which characteristic of an insurance contract states that, when loss occurs, the insured should be restored to the financial condition he was in before the loss?
Contract of Indemnity
Which type of authority holds that a producer may have whatever authority a reasonable person would assume the producer has?
Apparent
What are the characteristics of a major medical policy?
Deductible, coinsurance, and reimbursement benefits.
What is also known as ambulatory care?
OutPatient Care
What does first dollar coverage mean?
As soon as covered medical expenses are incurred, the policy begins to pay.
Under a Family Medical Expense policy, when are adopted children covered?
From the date of placement
According to the National Association of Insurance Commissioner’s Model Law regulating the sale of Long Term Care insurance, your first year’s commission on anLTC sale could be no more than what amount if your second year’s renewal commission is $400?
$800
What is the process used when an insurance company uses the claims history of a group in the underwriting?
Experience Rating
A proposed insured submits an application for life insurance without a premium payment, and the policy is delivered to the applicant. Which party made the offer?
Insurance company
A life insurance policy may be returned for cancelation and full refund if it is returned NO later than
20 days after receipt by the policyholder.
Which describes the tax consequences of a key employee disability policy?
Premiums are not tax deductible, and benefits are untaxed.
Which is the major reason why long-term care insurance is becoming increasingly important?
As life expectancy increases, the chances of needing long-term care also increases.
A few small employers in the same industry join together to become eligible for group insurance. The type of health insurance they have created for each other is known as
Multiple Employer Trust (MET)
Within the Framework of contact law, what is consideration?
Something of value
Under the individual health insurance policy provision law, within how many days must a notice of claim provided by the insured?
20
Eligibility for Medicaid benefits is primarily based upon which factor?
Income and Net worth
