Health Iv

Front 1

A certification of license status must contain all of the following EXCEPT:

* A) whether formal disciplinary action was taken during the last 4 years.
* B) the kinds of insurance for which the person is authorized.
* C) the licensee's license reference number.
* D) the licensee's previous employer.

Back 1

D

Upon request by any person, the Department shall issue a certification of the license status of any currently licensed producer or producer licensed within the preceding four years. Such certification shall contain the licensee's name, date of birth, license reference number, whether currently licensed or expired, kinds of insurance for which authorized (whether qualified by examination or the equivalent), and whether any formal disciplinary action was taken during the last four years.

Front 2

Which of the following managed care concepts was developed most recently?

* A) Preferred provider organizations.
* B) Exclusive provider organizations.
* C) Swing plans.
* D) The dual choice requirement.

Back 2

B

Exclusive provider organizations, or EPOs, are new types of Preferred Provider Organizations (PPOs) developed by companies to stay competitive in the managed care market.

Front 3

Mary has lost both legs as the result of complications caused by diabetes. Previously a horse trainer, she has taken a position as a computer programmer. Nonetheless, her insurance company pays her benefits under her disability income insurance policy under which of the following provisions?

* A) The own occupation provision.
* B) The flat amount benefit provision.
* C) The partial disability provision.
* D) The presumptive disability provision.

Back 3

D

Even though Mary can work, she will receive her disability income benefits for the stated term because of the severity of her condition. The nature of her disability raises the presumption that she is totally disabled.

Front 4

All of the following are examples of social insurance EXCEPT:

* A) Medicare.
* B) Social Security.
* C) Blue Cross and Blue Shield coverage.
* D) workers' compensation.

Back 4

C

Social insurance is provided by the federal and state governments and includes Social Security (death, old-age and disability benefits), Medicare, Medicaid and workers' compensation. Blue Cross and Blue Shield are examples of service insurers.

Front 5

Ron is covered under a group dental insurance plan through his employer. His plan requires that he use a dentist who is specifically listed in the plan. The dentist he chooses will be compensated for care rendered to Ron by a flat per capita fee paid by the insurer and by a co-payment fee paid by Ron with each visit. This type of plan is most likely:

* A) a preferred provider organization.
* B) an indemnity plan.
* C) a dental health maintenance organization.
* D) an exclusive provider organization.

Back 5

C

The fact that Ron has to use a dentist who is on a specified list and that dentist is paid on a flat per capita basis characterizes an HMO. The other options listed permit the insured to use any dentist he prefers, though coverage may be less with some than with others.

Front 6

Which of the following statements regarding experience versus community rating by group health insurance plans is CORRECT?

* A) Community rating takes the group's previous claims experience into account.
* B) Community rating is more cost effective and competitive.
* C) Premiums for group insurance are typically not based on experience rating.
* D) Experience rating is based on past and projected medical costs of the group.

Back 6

D

Experience rating is based on the actual loss experience of the group and is generally more cost effective than community rating. Community rating is based on the average charge for insurance among all insureds in a community. It does not take into consideration the difference in risk among insureds. With community rating, the same rate structure is used for all subscribers, regardless of their past or potential loss experience. Premiums for group insurance are typically based on experience rating.

Front 7

Benefit periods for short-term disability income policies typically vary from:

* A) one to 12 months.
* B) six months to two years.
* C) three months to three years.
* D) one to five years.

Back 7

B

Benefit periods for short-term disability income policies typically vary from six months to two years. In contrast, long-term disability policies carry benefit periods of two years and longer.

Front 8

An applicant for health insurance completes the application and satisfies all of the conditions of the conditional receipt. If the policy is eventually issued as applied for, coverage takes effect:

* A) as soon as the underwriting process has been completed .
* B) as soon as the policy has been issued.
* C) as soon as the policy has been delivered to the applicant.
* D) just as if the policy had already been issued.

Back 8

D

If the initial premium was paid with the application, the applicant satisfies all of the conditions of the conditional receipt, and the policy is eventually issued as applied for, coverage takes effect just as if the policy had already been issued.

Front 9

Which kind of deductible is entirely or partially absorbed by a basic medical expense policy?

* A) Corridor.
* B) First dollar.
* C) Integrated.
* D) Decreasing.

Back 9

C

All or part of the integrated deductible is absorbed by, or integrated into, the basic medical expense policy. Then major medical benefits are payable.

Front 10

All of the following provisions are optional in an individual health insurance policy EXCEPT:

* A) misstatement of age provision.
* B) unpaid premium provision.
* C) incontestability provision.
* D) change of occupation provision.

Back 10

C

An incontestability provision stating that 2 years after the date of issue, no misstatements on the application can be used to void the policy or deny a claim (except fraudulent misstatements), is a mandatory provision in all individual health insurance policies. Three optional provisions are change of occupation, misstatement of age, and unpaid premium. A change of occupation provision provides for a change in benefits or premiums if an insured changes his occupation from a high-hazard occupation to one that is less hazardous and vice versa. A misstatement of age provision provides that if the insured's age was misstated, the insured will receive the benefits that the premium paid would have purchased at the correct age. An unpaid premium provision states that when a claim is paid, any premium due and unpaid may be deducted from the claim payment.

Front 11

Which of the following statements regarding a conditionally renewable policy is NOT correct?

* A) The insurer may refuse to renew the contract as the result of the insured's deteriorating health.
* B) The insured has the conditional right to renew the policy up to a given age.
* C) The insured has the conditional right to renew the policy up to a given date.
* D) The insurer may refuse to renew the contract as the result of the insured's retirement.

Back 11

A

Although an insurer may refuse to renew the policy as the result of specific circumstances (such as the insured's retirement), it may not refuse renewal as the result of the insured's deteriorating health.

Front 12

Which of the following is the best reason why a medical plan would require a concurrent review for hospital patients?

* A) The patient is discharged in the shortest possible time.
* B) Quality care is assured at the most reasonable expense.
* C) The doctor and the patient consult on discharge times.
* D) The insurance company and the health care providers make decisions jointly.

Back 12

B

Concurrent review is a medical decision attempting to ensure that the hospital stay is as short as possible, yet still appropriate for the patient's medical condition. Providers may consult with other providers to discuss alternatives, such as home health care, or hospice care.

Front 13

Steve has an individual disability income policy that pays $600 a month if he becomes disabled. After he became disabled, he received a lump-sum payment of $10,000 in addition to his base benefit. Which of the following disabilities would result in this additional benefit?

* A) His disability involved a back injury that occurred while he was at work, and the additional benefit is paid under workers' compensation.
* B) His disability, which resulted in blindness, occurred in a car accident and is covered under the accidental death and dismemberment rider attached to his disability policy.
* C) His disability was caused by diabetes, and the additional benefit was paid under his medical insurance plan to cover the cost of special treatments.
* D) His disability resulted from a fall at home and is covered by his homeowners' insurance.

Back 13

B

An AD&D rider can be added to some individual disability income policies. Because Steve was disabled in an accident that resulted in blindness, he is entitled to the capital sum, which in this case is paid in a lump sum of $10,000. This benefit will not be paid for a disability resulting from illness, nor would workers' compensation generally pay a lump-sum benefit.

Front 14

Which of the following falls under the definition of a limited policy?

* A) A flat-benefit disability policy.
* B) Long-term care insurance.
* C) Accidental death & dismemberment (AD&D) insurance.
* D) Prescription drug plan.

Back 14

D

Prescription drug policies may be sold as supplements to individual policies or as stand-alone limited plans. LTC insurance covers a broad range of expenses involving long-term care. AD&D insurance generally also covers numerous perils related to accidental injury. A flat-benefit DI plan pays a fixed benefit for disabling accidents and injuries.