Missouri Health Insurance Lisensure Exam

Front 1

Time before coverage goes into effect for specified conditions (preexisting conditions)

Back 1

Probationary Period

Front 2

Time before an employee is eligible to enroll for group benefits

Back 2

Waiting Period

Front 3

Time one must wait from the point illness/injury occurs until you begin receiving benefits (LTCi, DI) (30-180 days)

Back 3

Elimination Period

Front 4

What are the 4 actions that can be taken after the underwriting process?

Back 4

Issue Standard, Issue Rated-Up (higher premium), Issue with Exclusions/Limitations (Impairment rider to not cover some conditions), Rejection

Front 5

What are the 2 GROUP ratings to determine premiums?

Back 5

community (based on geography) plans and experience (based on claim history) plans

Front 6

Group plan that requires employees and employers to contribute to premiums requiring 75% participation

Back 6

Contributory Plan

Front 7

Group plan in which employers pay all premiums; requires 100% participation

Back 7

Noncontributory Plan

Front 8

Medicare is primary UNLESS you are...

Back 8

still working and covered under a group plan at an employer with more than 20 workers. Then your group plan is primary.

Front 9

What are the requirements of COBRA?

Back 9

Consolidated Omnibus Budget Reconciliation Act 1985
- to allow employees to continue health coverage after termination or reduction of hours
- work must employ 20+ employees
- 18 months of coverage available
- 36 months of coverage available to dependents if you die, divorce, go on Medicare, or dependent is no longer a dependent
- may require the former employee to pay up to 102% of premiums

Front 10

What is HIPAA?

Back 10

Health Insurance Portability and Accountability Act 1997
- Guarantees protection for those with preexisting conditions
- Must have 18 months of creditable coverage with no lapse of more than 63 days

Front 11

Coordination of Benefits for Children

Back 11

If both parents have a group plan, the parent with the birthday first in the year will provide the primary coverage for the children.

Front 12

Earned Premium

Back 12

The portion of the premium that applies to the expired/used portion of the policy.

For example, if a $1,000 policy has a two-year life span and no claim has been filed six months into the policy, the company will have an earned premium amount of $250. (1/4 through the policy, 1/4 of the premium is Earned)

Front 13

Insured

Back 13

person applying for coverage through indemnity provider (reimbursement)

Front 14

Subscriber

Back 14

person applying for coverage through a service provider

Front 15

Blue Cross Blue Shield

Back 15

Blue Cross = Hospital
Blue Shield = Physician
Prepaid plans where subscriber pays a set fee for doctor & hospital services paid at a negotiated fee.

Front 16

Health Maintenance Organization

Back 16

Managed health care system providing medical services at a prepaid basis limiting the choice of care. Providers paid a flat amount. No rx coverage unless specifically added. Emphasize preventative medicine. Use a gate keeper to keep costs low. Subscriber may not go outside the HMO without prior approval.

Front 17

PPO

Back 17

Preferred Provider Organization - selected hospitals and practicitioners in a certain area providing services at prearranged cost. Providers are paid on a fee-for-service basis.

Front 18

Premium Delay Arrangement

Back 18

Allows employer to defer payment of monthly premiums to use for other purposes

Front 19

Reserve-Reduction Arrangement

Back 19

employer can retain the amount of annual premium to the claim reserve amount

Front 20

Retrospective-Rating Arrangement

Back 20

if claims exceed expectation, employer pays additional premium

Front 21

Point of Service

Back 21

Mixture of HMO/PPO; if in-network, benefits paid like HMO; if out, benefit pays like medical expense/PPO with high deductible/copayments.

Front 22

Time Limit on Certain Defenses

Back 22

The insurer cannot deny a claim on the basis of a preexisting condition/misrepresentation after the contestable period (usually 2 years). Except in cases of fraud, then no time limit.

Front 23

Reinstatement

Back 23

Allows insured to reinstate policy that has lapsed due to nonpayment -- at insurer's discretion

Front 24

Grace period

Back 24

7 days for weekly policy
10 days for monthly
31 days for all other lengths
before the policy lapses

Front 25

Notice of Claim

Back 25

Required by insured within 20 days of loss; every 6 months for a disability policy

Front 26

Claim Forms

Back 26

Insurer must send claim form within 15 days of Notice of Claim

Front 27

Proof of Loss

Back 27

Insured must provide evidence within 90 days

Front 28

Time payment of claims

Back 28

by insurer is immediate

Front 29

Legal action

Back 29

insured must wait 60 days after proof of loss to take legal action against insurer

Front 30

If you switch to a more hazardous occupation...

Back 30

your benefits may decrease.

Front 31

Insurance with Other Insurers

Back 31

Coordination of Benefits for individual policies: any one insurer's liability is limited to the proportion of the loss. Total benefits of policies known before loss divided by total benefits of policies known after loss.

Front 32

Unpaid Premiums

Back 32

Allows an insurer to deduct unpaid premiums from a claim that has occurred during a grace period.

Front 33

Occupational Policy

Back 33

Coverage ON and OFF the job

Front 34

Nonoccupational Policy

Back 34

Coverage OFF the job only.

Front 35

Accidental Bodily Injury vs. Accidental Means

Back 35

Accidental Bodily Injury covers injuries that are unintended & unforeseen.
Accidental Means - injuries and cause must be unintended and unforeseen (jumping from a ladder is not covered)

Front 36

Noncanellable

Back 36

insured able to renew to age 65 with no increase in premiums!

Front 37

Guaranteed Renewable

Back 37

GR - insured able to renew policy but premiums may increase GRR

Front 38

Conditionally Renewable

Back 38

Renewable unless a termination notice is given by insurer

Front 39

Optionally Renewable

Back 39

Renewable only at option of insurer

Front 40

Cancellable

Back 40

Insurer or insured may cancel at any time

Front 41

Attending Physician's Statement

Back 41

can be required when client requrests a medical expense or disability policy (to avoid adverse selection)

Front 42

Concurrent Review

Back 42

insurer monitors insured's hospital stay to prevent unreasonable costs

Front 43

Ambulatory Outpatient Care

Back 43

monitors effectiveness of outpatient services - dental, vision, family planning, preventative care

Front 44

Residual Disability

Back 44

benefits for loss of income when insured returns to work but is not able to work as much

Front 45

Presumptive Disability

Back 45

Assumed after loss of sight, hearing, speech or 2 limbs

Front 46

Buy Sell Agreement

Back 46

Disability income to one partner to buy out a disabled partner - premiums are NOT tax deductible; benefits are NOT taxable.

Front 47

Qualification for social security

Back 47

no gainful employment for 12 months

Front 48

The most important factor for disability insurance:

Back 48

OCCUPATION

Front 49

How long is a newborn infant covered?

Back 49

31 days

Front 50

How long is a wellness plan for children effective?

Back 50

Through age 12

Front 51

When is general enrollment and effective date for medicare?

Back 51

Jan 1 - Mar 31; July 1

Front 52

What is covered under Medicare Part A?

Back 52

Hospitalization including RX, Post hospital skilled nursing, Home health care for limited, specificed periods, Hospice Care, 3 pints of blood

Front 53

What is a short-term policy benefit period?

Back 53

13-104 weeks

Front 54

What are standard risk classifcations?

Back 54

age, health habits and occupation

Front 55

Representations

Back 55

are true to the best of one's knowledge

Front 56

How long does disability pay?

Back 56

2 years or until you return to work

Front 57

MIB

Back 57

Medical Information Bureau is a database of all insurance information

Front 58

What is the minimum amount of people in an assocation sponsored group?

Back 58

100 - plus group must exist other than for the purpose of buying insurance

Front 59

Group Underwriting

Back 59

All eligible members must be covered

Front 60

Group Policy Pricing is based off of what?

Back 60

ration of males to females and the average age in the group

Front 61

What is the conversion period to transition onto Cobra?

Back 61

31 days!

Front 62

How long is the required examination period for a LTCi or Medicare Supplement policy?

Back 62

30 days

Front 63

Inflation protection on LTCi policies

Back 63

is required to be offered, but optional for the insured.

Front 64

What are LTCi policy triggers?

Back 64

Incapable of performing 2 ADL's; cognitive impairment; physician's certification