Many major medical policies include a provision whereby when expenses reach a certain dollar amount, the insured no longer shares in the cost of expenses; the insurer pays 100% of remaining covered charges. This is referred to as the
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Qualified health plans (QHP) that a part of the Affordable care act are soldOnly on the Heath insurance exchangeWhich of the following classification of risks would typically have the lowest premium paymentpreferred risksMedicare coverage part B coversMedical care provided by physicians and other medical servicesBefore Cranston was disabled, he was a full-time engineer earning about $70,000 annually. Now, 2 years later, he is able to work part-time, earning about $25,000 annually. It is likely that Cranston would be classified aspartially disabledThe usual payment arrangement under a preferred provider organization contract isfee for serviceAn expense load is also known asthe insurers operating costsWhat is the proper term for a company owned by its policy ownersmutual insurance companyWhich of the following is covered by Medicare part aInpatient hospital coverage for a semi private roomAn injury that causes a person To only be able to perform some but not all of the essential duties of his or her occupation isA partial disabilityWhich health insurance policy provision states that after two years from the date of policy issue, no mistakements by the applicant, except for fraudulent mistakements, will void the policyTime Limit on Certain DefensesWhich of the following methods of handling risk means that the individual will pay for the loss if it occursretentionSecond surgical opinions, pre-authorization, limits on length of stay, and outpatient benefits are all elements ofReducing hospital care costsAlma, age 35, earns $50,000 a year and expects to retire when she is 65. What is Alma's human life value?$.15 millionWhich of the following is not considered an activity of daily living (ADL)WorkingAn insurance contract is an aleatory contract. This meansequal value is not given by both parties to the contractWhich of the following phrases correctly describes MedicaidProvides medical benefits for certain low-income people, for the disabled, and for families with dependent childrenAn insured's disability income policy defines total disability as the insured's inability to perform the duties of any occupation for which he is reasonably qualified by education, training, or experience. This definition is known as theAny occupation definition and is more restrictive than other definitions The any occupation definition of total disability is more restrictive and less favorable for the insured than the owner occupation definition of total disabilityIn health maintenance organizations, the use of a primary care physician, or PCP, is common as part ofthe gatekeeper conceptAll of the following are common exclusions and a disability income policy except: A. Self-inflicted injury B. A reoccurring disability C. Military service D. Living overseasB. A reoccurring disability No policy pays for every occurrence or event that can take place. The common exclusions for disability income policies are -war or military service -attempted suicide and other self-inflicted injury -noncommercial aviation -Commission of a felony -living overseasA child may be a dependent be on the ages of 26Only if the child is permanently mentally or physically disabled before that ageHealth maintenance organizations are required to provide for all of the following except: A. Hospital services B. Preventative care C. Emergency services D. prescription drugsPrescription drugsThe relative frequency of deaths in a specific population is known asmortalityIn group insurance, the evidence of an agreement between the insurer and the employee or association is theContractThe elimination period in a disability policy may be thought of astime deductibleThe type of healthcare provider that is a managed care entity and provides both healthcare services and healthcare financing is aHealth maintenance organizationEmployer-paid premiums for employee group health insurance are generallytax deductible to the employer and nontaxable to the employeesProtects dependents of employees by mandating for them the same extension and conversion privileges available to employees covered by group plansCOBRAThe intentional failure to disclose known facts is known asconcealmentThe punishment for fraud or making false statements may includefines, imprisonment, or bothFor a contract to be binding, both parties must have the legal capacity to make a contract. This principle is known asCompetent partiesWhen a group plan is contributory, what percentage of employees must want and be willing to pay for coverage75%All of the following are elements of a contract except A. Assignment B. Offer and acceptance C. Consideration D. Legal purposeA. AssignmentAn insurance policy is a unilateral contract becauseonly the insurance company is bound to live up to its side of the agreementCompared with individual disability income policies, group disability income policies are generallyless costly and have less benefit optionsDread disease, travel accident, vision care, and hospital income (indemnity) policies are all examples ofLimited policiesPolicy that Covers a number of individuals who are exposed to the same hazards, such as members of an athletic team, company officials who are passengers in the same company plane, and so on.Blanket policyWhen medical expense policies do NOT state specific dollar benefit amounts but instead base payments on the charges for like services in the same geographic area, benefits are designated as which of the following?Usual, Customary & Reasonable (Charges)The type of health insurance policy most likely used to cover all students attending a large university is known asa blanket policyA deductible that is measured in time rather than dollars is calledAn elimination periodRegarding long-term care insurance, the existence of symptoms that would cause an ordinarily prudent person to seek diagnosis or treatment, or condition for which medical advice or treatment was recommended by or received from a provider of healthcare services within six months before the effective date of an insured's coverage is known asPre-existing conditionWhich of the following statements regarding health savings accounts is not correct A. Earnings and HSA's grow tax free B. Account beneficiaries can make tax-free withdrawals to cover qualified healthcare costs C. Qualified health care expenses include Medicare supplement premiums D. The maximum annual HSA contribution is based on the statutory limit for the individuals type of coverageC. Qualified health care expenses include Medicare supplement premiumsAn individual who requires 24 hour a day supervision by skilled medical professionals in a nursing home receives what kind of careSkilled nursing carePetra is self-employed and pays $5,000 a year in premiums for health insurance covering her family. If her spouse also works and is covered by an employer-sponsored health plan, what is the maximum income tax deduction that Petra can take for her health insurance coverage?$0Routine dental services include all of the following except A. Cleaning B. Fluoride treatment C. Gum surgery D. X-raysC. Gum surgeryAll of the following are methods of handling risk except A. Repetition B. Transfer C. Avoidance D. SharingA. RepetitionPrior to the affordable care act, according to HIPAA, a newly hired worker was not subject to a waiting period for pre-existing conditions if she had less that how many days between jobs with no health insurance coverage63 daysWhich of the following statements regarding medical expense policies for people who are self-employed is not true A. Premiums are not tax deductible B. Premiums are deductible if the business shows a net profit at the end of the year C. Premiums are not deductible if the insured is eligible to participate in a group health plan D. Benefits are not taxableA. Premiums are not tax deductibleIf a disability policy provides hospital care benefits, it must also cover at least how many days of skilled nursing care30 daysDread disease policies generally cover diseases thatdo not occur frequently, but involve significant costs when they do occurHow often does a nonresident intermediary have to pay the $70 regulation fee in order to renew his or her Wisconsin licenseBienniallyThe commissioner may grant a temporary license to which of the followingThe family member of a disabled IntermediaryIn Wisconsin, a person who Knowingly and willingly obtains information about an individual from an insurer or insurance organization under false pretenses may be fined up to$25,000 or Imprisoned for 9 months or bothRelated costs associated with a surgical expense policy do NOT includeroom and boardMultiple Employer Trust (MET)A group of small employers who do not qualify for group insurance individually, formed to establish a group health plan or self-funded plan.Which of the following may be used as a reason to cancel long-term care policyNonpayment of premiumsNonqualified withdraws from a health savings account or subject income taxes and a penalty of20%Leonard owns a major medical health policy that requires him to pay the first $200 of covered expenses each year before the policy pays its benefits. The $200 is the policy'sDeductibleThe ABC ensure renewed his client's Health insurance policy with 28% higher rates than the original policy. The policy owner canCancel the renewal policy within 60 days after receiving itIn Wisconsin, the term intermediary is synonyms of which of the following termsAgentWhich of the following advertising terms describes a statement made by an individual, group of individuals, society, or association that makes no reference to the individual or group experience under the policyEndorsementWhich of the following statements regarding a health savings account (HSA) is not true A. Distributions are tax-free for qualified medical expenses B. Earnings grow tax deferred C. Contributions are taxed as ordinary income D. Enrollment in a high-deductible health plan is requiredC. Contributions are taxed as ordinary incomeIn an insurance transaction, an insurance producer who sells insurance policies to the public representsinsurerHow many hours a prelicensing education must be completed by the first-time applicant For a Wisconsin agent's license who wants to sell life, accident, and health insurance32 hoursThe abbreviation PDP refers to which part of MedicarePart DIf a person knowingly aids his or her employee and breaking a Wisconsin insurance law, he or she willLiable for a fine up to $5000 or 3 years imprisonmentA petition for rehearing may be submitted with it how many days after the commissioners order has been issued20 daysUnder many disability income insurance policies, which of the following is generally NOT considered a presumptive disability?Loss of a legLawrence signed an application for a life insurance policy on September 2, and took a required medical exam on September 4. He gave the agent a check for the initial premium and received a conditional receipt at the time of application. The policy was issued as originally applied for and the agent delivered the policy to him on October 15. The earliest effective date for Lawrence's insurance policy would be:September 4Resident insurance intermediaries must pay regulation fees of$35 every two yearsIf a claim is made on a health and accident insurance policy for health care services provided by a licensed nurse practitioner, the policyMust pay the claim, unless the policy specifies that the services must be provided by a physicianHow long must records of a replacement notice be kept by the replacing insure5 yearsJennifer's dental plan covers routine dental care at 80% (after the deductible), but major dental care is covered at 50%. Which of the following types of dental treatment would most likely have a 50% coinsurance requirement?Creation of a fixed bridge Well minor post orthodontic treatment, such as the adjustment of bridges and repair of dentures, is generally covered as a routine care, the creation of a bridge or dentures is generally covered as a major expense and subject to a higher coinsurance requirementgrandfathered health policyexisted prior to the ACA, costs may not increase and benefits may not be reduced on these policies, not required to comply with some consumer protections of ACAAll license producers, Public adjusters, and consultants must complete how many hours of continuing education courses24 hours every 2 yearsMajor medical policies that pay 100% of covered expenses above a specified amount and after the insurance deductible contain what kind of provisionStop-lossA relatively small flat dollar amount that HMO subscribers pay for each doctor visit is known asCopaymentsEach unmarried child under age 18 (or 19 if in high school) receives a benefit equal to what percentage of the disabled worker's PIA?50%The calendar year deductible provision of a major medical policies stipulates thatThe deductible is applied only once during the calendar yearelimination (waiting) periods in disability income policies are designed tospecify a limited period of time at the start of disability when benefits are not payable.What is the minimum number of home care visits that a health and accident policy issued in Wisconsin may cover in a 12 month period40 home health care visitsPayment on an insurance claim is not considered overdue if it is made within 30 days. If a claim goes beyond 30 days, it is subject to bear simple interest at what rate per year7.5%Which of the following employee populations may an employer legally exclude from group health benefitsUnion workers as a classWhich of the following statements regarding individual and group health plans is not correct? A. All accidents are covered in a group plan B. An individual plan issues a policy C. In an individual policy, coverage is renewable at the option of the insured or insurance D. In the group plan, there is no individual underwritingA. All accidents are covered in a group planAll of the following medical expenses are generally excluded from coverage under individual medical expense policies except A. Nursing care at home B. Treatment for drug and alcohol abuse C. Custodial care in a convalescent facility D. Nursing care in the hospitalD. Nursing care in the hospitalElaine signs an application for a $50,000 nonmedical life policy, pays the first premium, and receives a conditional insurability receipt. If Elaine were killed in an auto accident two days later? A) the premium would be returned to Elaine's family because the policy had not been issued. B) the company could reject the death claim because the underwriting process was never completed. C) her beneficiary would receive $50,000, if Elaine qualified for the policy as applied for. D) the company could reject the application on the basis that death was accidental.C) her beneficiary would receive $50,000, if Elaine qualified for the policy as applied for. A conditional insurability receipt is given after an application for life insurance is completed and a check for the first premium is also given. As long as the company finds the applicant qualified for the policy at the time of signing, the death benefit will be paid.Social Security defines disability as the inability to engage inThe duties of any occupationWhich of the following is usually covered by an individual major medical expense insurance policy? A. Injuries due to accidents B. Custodial care performed by a healthcare professional C. Situations involving deliberate acts of the insured, such as self-inflicted injuries D. Losses that are covered by Worker's CompensationA. Injuries due to accidentsWhat is one of the primary considerations of a disability buyout policy A. The elimination period B. The beneficiaries C. The effective date D. The premiumThe Elimination periodThe purpose of a health savings account is toServe as a tax favored way to accumulate funds to cover medical expensesIn Wisconsin, policies that cover hospital expenses must cover how much of the expenses of inpatient and outpatient treatment of kidney disease in a year$30,000In major medical and comprehensive medical expense policies, a coinsurance provision A. Provides for percentage participation by the insured B. Helps to satisfy the deductible amount C. Does not apply until benefit amounts exceed $2000 D. Has no effect on claimsProvides for percentage participation by the insuredUnincorporated groups of people that agree to insure each other's losses under contract are known asReciprocal insurersWhen the commissioner examines the affairs of a person engaged in the insurance business in Wisconsin, who pays for the cost of the examinationThe person being examinedThe period of time an employee must wait before Becoming eligible to enroll in an employer - sponsored health plan is calledthe probationary periodWhich of the following coverages must be included in all Medicare supplement policiesCost of the first 3 pints of bloodAfter hearing, what is the maximum court-ordered fine a licensee will pay for failing to comply with the commissioners order or continue to violate Wisconsin insurance law within two weeks of its issuanceUp to $5,000 a day each day of the violation continues beyond the 2-week periodWhich of the following is not required when reinstating a revoked licenseComplete prelicensing education for each line of authorityAll of the following are optional provisions in an individual health insurance policy exceptlegal actions provisioncoordination of benefitsA provision that helps determine the primary provider in situations where an insured is covered by more than one policy, thus avoiding claims overpayments.The insurance security fundprotects insureds against losses from unpaid claims if an insurer is liquidatedEvery accident and health insurance policy issued in Wisconsin must contain all of the following provisions exceptLong-term care coverageTanya 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 presumptive disability provision B) The own occupation provision C) The flat amount benefit provision D) The partial disability provisionThe presumptive disability provision Explanation Even though Tanya 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.How soon should a claimant give notice or proof of loss to an insurerwithin 1 year after the time required by the policyWhich of the following types of plans integrates it's coverage with basic medical expense coverage, providing benefits in excess of those specified in the basic planSupplementary Major MedicalHow often does a resident intermediary have to pay the $35 regulation fee in order to renew his or her Wisconsin licenseBienniallyThe purpose of a medical expense insurance is toreimburse the insured for expenses incurred for medical care, hospital care, and related services.Marta is covered by two group health policies: One provided by her employer and the other provided by her spouses employer. The coverage provided by her spouses policy is calledSecondary coverageDental insurance plans manage costs by using all the following measures except A. Setting a maximum dollar limit on benefits that the insured can receive during one year B. Limiting the type of services that the plan will cover C. Limiting the number of services that the plan will cover D. Eliminating all coverage for specified periodsD. Eliminating all coverage for specified periodsWisconsin health insurance risk-sharing planProvides health coverage for people who are unable to otherwise obtain insurance because they are believed to present to great of risk to ensure. Anyone who has tested positive for the presence of HIV is automatically eligible for coverage but Wisconsin HIRSP.Which kind of health insurance policy ensures renewability up to a specific age of the insured, although the insurer reserves the right to change the premium rate on a class basisGuaranteed renewableWhich of the following statements best defines why an applicant would want to backdate and insurance applicationTo have the policies premium based on the insured's age at an earlier dateFamily coverage under an individual or group accident and health insurance policy for handicap child shall be effectiveAs long as the child is unable to work and is dependent on the insuredA dental insurance plan that pays a capitation fee to the dental provider isDental health maintenance organizationHow long most records of financial transactions between ensures and their policy holders be maintainedThree yearsdental health maintenance organization (DHMO)A dental capitation plan in which comprehensive care is provided to enrollees through participating providers. The dental provider receives a monthly payment for each enrollee accepted, and enrollees generally are required to remain in the program for a specific period. Also see capitation.What is the minimum number of days that a group health an accident insurance policy must provide as a grace period, if the policyholder does not give notice that he or she will discontinue the policy31 daysThe commissioner gives approval to an insurer to do business in Wisconsin through aCertificate of authorityAll of the following are required provisions of accident and health insurance policies except A. Inflation protection B. Grace period C. Reinstatement D. Notice of claimInflation protectionAn agent that hires, trains, and supervisors other agents within a specific geographical area isA managing general agentManaging General AgentAn authorized agent of the primary insurer that manages all or part of the primary insurer's insurance activities, usually in a specific geographic areaHarry, the owner of a convenience store, is the insured under a business overhead policy. We're hairy to become disabled, the policy would cover all the following exceptHarry's salary Business overhead expense policies do not include any compensation for the disabled owner ofCaptive Agentan insurance agent who represents only one insurance company and who is, in effect, an employee of that companyEmployers must provide notification statements to individuals eligible for COBRA continuation within14 daysEligibility for Medicare supplement policies can best be described asOpen to all qualified applicantsThe insured has a $2500 individual deductible and $7500 Family deductible. The insured has an injury in February resulting in $6000 of medical expenses. Later in the same year her spouse incurs $4000 of medical expenses. How much will of these expenses will not be paid by the insurer$5,000 The insured and spouse will each have to pay a $2500 deductibleWhich of the following would most likely happen if an applicant is determined to be a preferred riskThe policy will be written with a discounted premiumWhen the first premium is collected at the time of application for a policy, the effective date of coverage isThe date on the application or the date of the medical exam, if requiredAccording to the time limit on certain defenses provision, unless an insured has made fraudulent Miss statements, a health policy is inccontestible after2 yearsThe capital sum in an accident policy isthe amount paid to the insured for dismemberment or loss of sightAll the following are alternatives an insurer has when asked to insure a substandard risk exceptissue the policy with a probationary period after which the insurer may continue or cancel the policyWhich of the following provides coverage for death or injury resulting from accidents occurring while the insured is a fare-paying passenger on a common carrierTravelAll statements made by an applicant in an application for life insurance are considered to berepresentationsAll of the following are benefits provided under part a of Medicare exceptphysicians' services for inpatient careWhat major medical term describes the concept that the insured must pay up to a certain dollar amount of medical expenses before the insured pays any of the medical expensesDeductibleWhat is the purpose of the fair credit reporting actTo give the consumer recourse if insurance is denied on the basis of a credit reportA person in a position of financial trust isFiduciaryThe purpose of a Medicare supplement or Medigap policy is toHow cover cost not met by MedicareAn admitted insurer must have which of the following before transacting insurance in the stateCertificate AuthorityWhich of the following legal terms indicates that a life insurance contract contains the enforceable promises of only one partyunilateralAll of the following are required provision and health insurance policies except A. Change of occupation B. Entire contract C. Grace period D. Notice of claimWhen are disability income benefits received as non-taxable income to the recipientAlwaysStatements made by an applicant for life insurance that are Guaranteed to be true arewarrantiesIn noncontributory group health plans, How many eligible employees must be covered by the plan100%A self-employed person may deduct the IRS approved percentage of premiums paid for health coverage if sheis eligible to participate in an employer-sponsored group health planWhich of the following is not classified as an activity of daily livingWorkingSamantha filled out an insurance application with her agent. Her statements made on the application areRepresentationsconditionally renewable policythe policyholder can renew the policy until a specified age; however, the insurer has the right to decline renewal under conditions specified in the contractOptional Renewable Policies- Insurer has the option to terminate the policy by class, only a specific date that is stated in contract - Has option to increase premium by class as wellguaranteed renewable policyA health insurance policy that allows an insurer to change the policyowner's premiums, but NOT cancel the policy is called a(n)Cancelable policygrants the insurer the right to cancel the policy at any time and for any reasonDental Expense Insurancecovers exams, cleaning, x-rays, fillings, root canals, and oral surgeryDental Expense Insuranceprovides reimbursement for the expenses of dental services and supplies and encourages preventive dental careprobationary periodThe period of time between the effective date of a health insurance policy and the date coverage for all or certain conditions begins.IndemnificationThe insured is restored to his or her approximate financial position prior to the occurrence of the lossWhich health insurance provision states that the insurer will pay the death benefit promptlyProof of LossA statement of facts about a loss for which the insured is making a claim.The stipulation in a health policy that allows the insured to examine a policy for a specific number of days after delivery and return for a premium refund if desired is called the:free look provisionKeeping premium money separate from personal accounts is afiduciary responsibility of the agentElimination Periodamount of time that lapses after a disabling event before the insurance company begins to pay benefitsWhich of the following statements concerning dental care policies is correctComprehensive dental care policies usually pay a percentage of reasonable and customary charges for nonroutine treatment.Key Person Disabilitypurchased by the employer on the life of a key employee; the contract is owned by the business, the premium is paid by the business, and the business is the beneficiaryBusiness Overhead ExpenseProvides the funds to cover the overhead expenses of a business when the owner becomes disabled. The benefits include expenses such as office rent, utilities, and employee labor. However, the owner cannot collect for loss of income under this policy.Reducing Term Disability InsuranceA business disability policy under which, in the event of disability of the owner who has outstanding debt, the policy makes the loan payments.Adverse SelectionA high-risk person benefits more from insurance, so is more likely to purchase it.Risk may be defined as:Uncertainty of lossConditional ReceiptGiven to the policy owners when they pay a premium at time of application. Such receipts bind the insurance company if the risk is approved as applied for, subject to any other conditions stated on the receipt.Stock CompanyA company or corporation whose capital is divided into shares.Medigaphealth insurance plans that help pay expenses not covered by MedicareCirculation of a maliciously critical statement about any insurer's financial condition to injure the insurer is called:defamationMedicare supplement policies must beGuaranteed renewableUnder the misstatement of age provision in a health insurance policy, what can a company do if it discovers that an insured gave a wrong age at the time of application?adjust the benefitsJeff has a policy that will pay any expenses he incurs as the result of in-hospital medical treatment, as well as some of the expenses he incurs on an outpatient basis. Jeff probably has a: A. disability income policy B. long-term care policy C. medical expense insurance policy D. hospital income policyC. Medical expense insurance policyInsured losses are covered immediately after a policy is reinstated whenthe losses result from accidental injuriesA licensed producer may share commissions withHer highest performing employee who is licensedUnder COBRA, the right to continue existing group health coverage is NOT available to an individual whois terminated due to gross misconductFlexible Spending Account (FSA)a monetary account, offered through an employer, into which money is put through payroll deductions, before it is taxed. Funds can be withdrawn for qualified medical expenses as needed, but the funds must be spent each yearResidual Disability BenefitA disability income payment based on the proportion of income the insured has actually lost, taking into account the fact that the insured is able to earn some income.Partial Disability BenefitReduced disability income benefit payable if an insured has returned to work on a limited basis after a period of compensable totally disability, commonly equal to 50 percent of the monthly total disability benefit payable for up to six monthsWhen a group disability insurance plan is paid entirely by the employer, benefits paid to disabled employees areTaxable income to the employeeAn insured lets a health policy lapse, and he wishes to reinstate. If a conditional receipt is issued with the reinstatement application, after how many days will the policy be considered reinstated if the insurance company takes no action?45 daysPresumptive DisabilityA provision that is found in most disability income policies which specifies the conditions that will automatically qualify the insured for full disability benefits.Residual Disabilityapplies when you are gainfully employed and not totally disabled but, solely because of sickness or injury, our loss of income is at least 15 percent of your prior incomeOwn OccupationA definition of total disability. The insured must be unable to work at her own occupation. It is easier for the insured to receive benefits under policies using this definition.