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AD Banker Health Ins

Flash Cards for AD Banker Study Guide for Health Insurance

The policy conditions represent the obligations of: Both the insured and the insurer
One characteristic of life insurance is that the insurer is obligated to pay a claim in the event of the death of the insured, however, the insured is not contractually obligated to do anything other than keep the policy in force. This is a: Unilateral Contract
The Financial Privacy rule requires insurers to provide consumers with a privacy notice: At the time the consumer relationship is established and annually thereafter
An insurer authorized to do business within this state is considered what type of insurer? Admitted
______is generally an option only for large corporations who may want to limit their risk up to a certain dollar amount, then buy insurance above and beyond that amount Self-insurance
Before an insurer can operate in this state, it must have Certificate of Authority issued by the state Insurance Department
In a reinsurance transaction, the company that wishes to transfer all or a portion of the financial risk of loss is known as the _______ company. Ceding
An applicant completes the application and submits it to the insurer along with a premium check. When is the applicant's offer considered accepted? When the insurer issues a policy
An insurance company based out of Europe approved to do business in your state would be considered a/an: Alien, admitted
Insurance does not do what? Eliminate Risk
Why is a policy considered to be a contract of adhesion? One party prepares the contract with little or no input or negotiation from the other party
What are the two types of risk? Speculative and pure
The ________ department of an insurance company advertises and sells policies to the public. Marketing or Sales
A producer gathers information about the applicant for the insurer in order to avoid adverse selection. This is considered to be: Field underwriting
What factors are not used in underwriting an individual disability policy? Political affiliation and religious preference
Accident and Health policies provide coverages for all, except: Workers' Compensation claims
What is not a mode of Premium payment Single Pay
For an accidental means policy to pay a claim, the injury must be an: Unintentional in both the cause and the result of the injury
factors not used in the calculation of health insurance premiums Mortality Table
If the insurer issues a policy after receiving an application for health insurance in which preexisting conditions were inadvertently omitted, what would be the consequence to the insured's coverage if a preexisting condition caused a claim Coverage would be as stipulated in the policy because the company issued the policy even though the question was left blank
Field underwriting is very important: Due to the risk of a moral hazard
If a premium is collected at the time of the application, the producer will issue a: Conditional receipt
A premium is paid at the time of application and a conditional receipt is issued. If the policy is issued as applied for, coverage becomes effective: The date of the conditional receipt
This type of policy covers the treatment and care of the insured's teeth. Dental expense
Which of the following types of care is excluded in a Long-Term Care policy? Hospitalization in the Intensive Care Unit
Accident and Health insurers would use which of the following formulas in determining premium rates? Morbidity - Interest + Expenses
In respect to Accident and Sickness Insurance advertising Only a comparison of benefits is required when insurers advertise by comparisons of like products
Howard talks to his agent Jane about buying a critical illness policy from the XYZ insurance company to cover his wife Deborah, and naming his daughter Mary as the beneficiary in case of death. Jane told him that she didn't need a signature from Mary
The area of the dentistry profession dealing primarily with maintaining the functional use of natural teeth, is called: General dentistry
common exclusion in a medical expense plan: Loss due to Workers' Compensation
A Basic Hospital Expense Policy provides coverage for the insured while ________. Confined to the hospital
A procedure used by dental insurance carriers to determine the benefit to be paid is known as: Precertification
HMOs do not provide Private hospital rooms
An insured is covered for medical expense at work. A friend and the insured join the U.S. Army. How does this affect the insured's group medical insurance? It ceases immediately when the insured is sworn in
Which limitations is not included in most dental expense insurance plans? Deductibles for preventive care
How do PPOs save consumers money? They charge patients within the PPO less than those who are not in the PPO
When will a primary care physician referral a HMO member to a specialist? Usually after all other treatments have been exhausted
The main purpose of requiring a Gatekeeper is to: Reduce costs within the plan
Sandra owns a Plan that contains a 60/40 Participation (Coinsurance) Provision and a $200 deductible. How much will Sandra and the insurer each pay under the coinsurance provision if Sandra's first medical claim for the year totals $10,200? The insurer would pay $6,000, and Sandra would pay $4,200
If a policy requires the payment of an additional premium for the continuation of coverage for a newborn, the insurer must be notified within 31 days of the ______. Date of birth
Which is the best description of a Limited Accident Policy? It provides specific benefits for specific injuries from specific causes
what is not correct concerning a Blue Cross and Blue Shield Plan? Benefits are paid directly to the insured individual
Dental plans are normally written with a stated annual maximum on the number of: Benefit dollars that will be paid
Group Disability Income is usually offered only on a nonoccupational basis, which will not cover work-related disabilities, because: Work related injuries are normally covered under Workers' Compensation
Between the ages of 19 and 65, a worker in America is more likely to be disabled rather than die. This is a comparison of: Morbidity to Mortality
Presumptive disability means Presumptive Disability involves the loss of two or more limbs.
A partial disability is defined as an individual: Unable to perform one or more duties of his/her occupation
Not possible business uses of Disability Income Insurance Workers' Compensation
Penelope received benefits from her disability policy and went back to work. After 30 days she found she was not able to work and began to immediately receive her disability payments. Which provisions made this possible? Recurrent Disability Provision
Joan was told she could only expect about 70% of her weekly salary on a disability check if she was ever disabled. The reason for this is to reduce _________. Malingering
A Disability Income Policy has a period of deductibility immediately following a disability during which time benefits are not payable. This period is called a(n): Elimination Period
Which disability income benefit periods will result in the highest premium? Life
Under what provision will a disability policy provide benefits if the insured is totally disabled because of donating an organ to another individual? Transplant
Attaching a(n) ___________ rider excludes coverage for a condition that would otherwise be covered. Impairment
he optional guaranteed purchase option rider allows the insured to purchase additional coverage in all of the following situations, except: Job change
Ole Olson owns a Business Overhead Expense Policy whereby if he should become disabled, the policy will continue to cover most business expenses in his absence. The policy would cover all of the following, except: Ole's personal lost income
What type of disability income insurance pays a lump sum enabling certain businesses to cover the cost of purchasing a disabled business owner's interest in the business? Business disability buyout
Part A of Medicare pays for: Hospital expenses
How long is the free look period for a Medicare Supplement policy? 30 days
Which will cover the cost of inpatient blood transfusions after the first 3 pints? A&B
Which is not covered by Medicare Part A? Outpatient hospital treatment
When must an insurer provide a Medicare Supplement Buyer's Guide and an Outline of Coverage? At the time of application
The Medicare Supplement Right of Return Provision (Free Look Period) allows the buyer a period of ________ to return a policy and receive a full refund. 30 days
If an individual starts receiving Social Security retirement benefits at age 62, when are they eligible for Part A benefits? Automatically at age 65
What is not covered by a long-term care policy? Hospitalization
What statement regarding Medicare is not true? Medicare is the primary payor to any employer group health plan coverage
Which Medicare Supplement policies have Core Benefits? A through N
In order to purchase a Medicare Supplement, an eligible individual usually must have Medicare Parts __________. A and B
If an individual is age ______ or over and continues to work, Medicare is usually the secondary insurer to any employer group health plan the individual participates in. 65
Which Act was implemented in order to protect consumers from questionable Medicare Supplement Policy marketing practices? NAIC Model Law
In general, which of the following Medicare plans does not require additional premium? Part A
Susan neglected to make her premium payment and she was injured in an accident. After she submitted the claim, she discovered that the insurer had subtracted $200 (the amount of the overdue premium) from the claim. This is allowed under which provision? Unpaid Premiums
All states have adopted the Uniform Individual Accident and Sickness Policy Provision Law. If an insurer changes any of these provisions, they must make sure it does not: Create a meaning that is less favorable to the insured than the original wording
Proof of loss is required within _____ days of loss. 90
Which statement is inaccurate regarding the Change of Occupation Provision? The insured must notify the insurer of a change of occupation, or the policy will be cancelled
What is the result of an insured not receiving a claim form within the time period allotted after submitting a notice of claim? The insured can submit written proof of the loss
Mandatory uniform provisions found in health insurance policies are designed to protect the: Insured
The grace period for an individual health insurance policy being paid on a quarterly basis is: 31 days
Precertification, Mandatory Second Surgical Opinion, and Concurrent Review are provisions in health insurance policies known as: Case Management Provisions
Right to Examine is the same as: Free Look Period
Every Health and Disability Income Policy must express the conditions and provisions for _______. Continuation of the contract
If the insurer cancels an individual health plan, what happens to the unearned premium? It is refunded on a pro rata basis
The Insuring Clause under an individual A&H policy does not contain Premium or rate calculations
Anna has a contract that includes the Non-Emergency Hospital Preauthorization Admissions Provision. For a scheduled hospital stay, she must first get preauthorization through her insurer. If she does not, the insurer may: Reduce her normal benefits
If the insurer cancels an individual health plan, what happens to the unearned premium? It is refunded on a pro rata basis
If the insured is receiving regular disability income payments, the insurer can require notice of continuance of claim every ______ months. 6
A carrier replacing employer group coverage is not required to cover all employees and dependents covered by, or eligible for, coverage under the previous policy if the replacement takes place more than ___ days after of the previous policy's termination. 60
Coordination of Benefits is a provision designed to reduce ________ when an insured is covered under multiple health plans. Overinsurance
A Small Employer is defined as any person, firm, corporation, partnership, or association that is actively engaged in business and has ______ employees or less. 50
What is consistent with group health underwriting? Each member of the group is covered regardless of his or her health history
An employee is considered full time and eligible for small employer medical expense insurance if he or she works a minimum of ________ hours per week. 30
A third party administrator is utilized in which plans? Self-funded plans
COBRA applies to employers with 20 or more employees
Which provision of group health plans is used to determine primary and secondary coverage when an insured is covered by more than one insurance plan? Coordination of Benefits (COB)
Under HIPAA, coverage may be nonrenewed for all of the following reasons, except: Frequency of claims
What is incorrect regarding the group underwriting process? Adverse selection is not a concern for group contracts
What is not true of the Coordination of Benefits Provision under a group plan In the event children are covered under two group plans, the insurer for the parent who is the oldest is primary, and the other parent's plan is secondary
What type of Language is permissible in advertising? Stating that 'We have been in business for over 50 years, for more information contact a local agent.'
An example of an inaccurate statement is Group insurance normally covers occupational injury or disease
HIPAA defines a pre-existing condition as one for which the insured received medical advice, diagnosis, care, or treatment within the past _____ months. 6
The federal law that governs employer-sponsored employee retirement and welfare and benefit plans is: ERISA
Which disability policies would be considered a deductible business expense? A business overhead expense policy
Group health insurance plans apply which of the following restrictions to dependent coverage on children of the primary insured up to age 26? They must be under age 26
Karen, age 50, withdraws $1,000 from her Health Savings Account (HSA) for a purpose other than a qualified medical expense. As a result of this action: The $1,000 is taxed as ordinary income, with an additional $200 penalty tax applied
After Robert signed up for Medicare, he withdrew 2000 from his HSA. He used 600 for his Medicare Supplement premium, 200 for out-of-pocket medical expenses, and the remaining 1200 on a trip. Later, when he paid his taxes for the year, he discovered $1,200 was subject to income tax
Some groups are considered to be exempt from the Affordable Care Act's requirement to purchase coverage. Not included is: Those who must pay less than 9.5% of their income for health insurance
What circumstances is the small business owner able to deduct the premiums they paid for insurance? The sole proprietor of a small firm buys an overhead expense policy
What regarding coverage for emergency care under the Affordable Care Act is correct? Plans must do so regardless of network affiliation without requiring prior approval
What is the maximum annual contribution to an FSA, which is allowed by law 2,550The benefits received from which of the following personal policies are received tax-free?
The benefits received from which of the following personal policies are received tax-free? Medical expense insurance, long-term care insurance, and disability income insurance
What statement is true regarding taxation of health insurance? The benefits received from a group Disability Income Policy paid entirely by the employer are fully taxable as income to the employee
group long-term care insurance program through his employer, what percentage of his benefits would be taxable based on the premium structure? 0$
What are not ways consumers can insure themselves with 'minimum essential coverage' without having to pay a penalty under the Affordable Care Act Be self-insured
The Bronze plan covers _______ of medical expenses. 60%
There are ____ different 'Metal Plans' offered through the health insurance exchanges. 4
A licensee may be required to wait for up to ______ years after license revocation before applying for a new license. 5
At least what percentage of the continuing education requirements for a producer or consultant must be classroom instruction? 50
A licensee must be at least ___ years of age. 18
A person must hold the appropriate ___________ to transact insurance business in Utah. License
The following are not reasons why the Commission may disapprove, or withdraw approval of, any form It fails to provide the producer's name, address, or business address, if for a basic policy or application (The producer's name and address is not found on any insurer's forms, policies, or applications.)
An insurance contract is valid even if purchased from a(n) _________ person. Unlicensed
A commission for selling insurance may not be paid to a person other than a licensed insurance: Producer
Licensees must notify persons about privacy practices at least once every _____ months. 12
Insured risk classification may be based upon which criteria? Age or health
A person violating an insurance law must pay the Department ______ times the amount of any profit gained from the violation, in addition to any other penalty. 2
A Certificate of Insurance or Outline of Coverage for a group policy must state the ___________ name on the cover. Insurer's
A producer or consultant must keep documentation of completing the continuing education requirements for ______ years after the end of the 2-year licensing period to which the continuing education applies. 2
An insurer or a producer may pay commissions to an insurance agency or to persons who do not sell insurance in Utah if the payment is: Not a prohibited inducement or rebate
A person may not knowingly hire a person who is not: Licensed
For a business entity, controlled business means insurance issued on the life, person, or property except Fellow chamber of commerce members