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Fundamentals of Financial Management, Concise Edition10th EditionEugene F. Brigham, Joel Houston 777 solutions All of the following are correct about the required provisions of a health insurance policy EXCEPT A. The entire contract clause means the signed application, policy, endorsements, and attachments constitute the entire contract. B. A reinstated policy provides immediate coverage for an illness. C. Policies become incontestable after being in force for 3 years. D. A grace period of 31 days is found in an annual pay policy. B. A reinstated policy provides immediate coverage for an illness. Accidental injury is covered immediately, but to protect the insurer against adverse selection, losses resulting from sickness are covered only if the sickness occurs at least 10 days after the reinstatement date. An insured pays a monthly premium of $100 for health insurance. What would be the duration of the grace period under the policy? A. 15 days B. 30 days C. 60 days D. 7 days B. 30 days The grace period is 30 days for all health insurance policies in Louisiana. Question 11 of 15 A. Insuring Clause. B. Pre-existing Conditions Clause. C. Eligibility Clause. D. Consideration Clause. D. Consideration Clause. The consideration clause specifies that both parties to the contract must give some valuable consideration. The payment of the premium is the consideration given by the applicant. Because the applicant had not paid an initial premium, she is not covered by insurance. Question 12 of 15 A. An estimate of the total amount of medical and hospital expense for the loss. B. A complete physician's statement. C. A statement that is sufficiently clear to identify the insured and the nature of the claim. D. A statement from the insured's employer showing that the insured was unable to work. C. A statement that is sufficiently clear to identify the insured and the nature of the claim. The Insurance Code requires that each policy must include, "Written notice of claim must be given to the insurer within 20 days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible". Question 13 of 15 A. The estate of the insured. B. The insurer. C. The state's autopsy fund. D. The limits of coverage under the health insurance policy. B. The insurer Where not forbidden by state law, the insurer, at its own expense, may cause an autopsy to be performed on a deceased insured. An insured notifies the insurance company that he has become disabled. What provision states that claims must be paid immediately upon written proof of loss? A. Time of Payment of Claims B. Incontestability C. Physical Exam and Autopsy D. Legal Actions A. Time of Payment of Claims The Time of Payment of Claims provision specifies that claims are to be paid immediately upon written proof of loss. Which renewability provision allows an insurer to terminate a policy for any reason, and to increase the premiums for any class of insureds? A. Conditionally renewable B. Cancellable C. Guaranteed renewable D. Optionally renewable D. Optionally renewable The renewability provision in an optionally renewable policy gives the insurer the option to terminate the policy for any reason on the date specified in the contract (usually a renewal date). Furthermore, this provision allows the insurer to increase the premium for any class of optionally renewable insureds. When an insurer issues an individual health insurance policy that is guaranteed renewable, the insurer agrees A. To charge a lower premium every year the policy is renewed. B.Not to change the premium rate for any reason. C. To renew the policy indefinitely. D. To renew the policy until the insured has reached age 65. D. To renew the policy until the insured has reached age 65. The guaranteed renewable provision is similar to the noncancellable provision, with the exception that the insurer can increase the policy premium on the policy anniversary date. As with the noncancellable policy, coverage is generally not renewable beyond the insured's age 65. Which provision concerns the insured's duty to provide the insurer with reasonable notice in the event of a loss? A. Notice of Claim B. Loss Notification C. Claims Initiation D. Consideration A. Notice of Claim The Notice of Claim Provision spells out the insured's duty to provide the insurer with reasonable notice in the event of a loss. In an optionally renewable policy, the insurer has which of the following options? A. Alter the due date so the policy can be cancelled sooner B. Shorten the notice that the insured receives C. Increase premiums D. Increase the grace period C. Increase premiums Optionally renewable policies allow the insurer to cancel a policy for any reason whatsoever. Policies can only be cancelled by class on the policy anniversary or premium due date (renewal date). If the insurer elects to renew coverage, it can also increase the policy premium. A health insurance policy clause that prevents an insurance company from denying payment of a claim after a specified period of time is known as the A. Insuring clause. B. Time Limit on Certain Defenses clause. C. Misstatement of Age clause. D. Reinstatement clause. B. Time Limit on Certain Defenses clause. The Time Limit on Certain Defenses provision guarantees that a misstatement made in the application, unless it is fraudulent, cannot be contested after the first 3 years of the policy. An insured purchases a health policy in 2000 and submits a claim in 2005. The insurance company discovers at that time that the insured misstated the information about his health condition. What will the insurer most likely do? A. Deny the claim B. Pay a decreased benefit C. Void the policy D. Pay the full benefit D. Pay the full benefit The Time Limit on Certain Defenses provision stipulates that no statement or misstatement (except fraudulent misstatements) made in the application at the time of issue will be used to void a policy or deny a claim after the policy has been in force for 3 years. While a claim is pending, an insurance company may require A. The insured to be examined only once annually. B. An independent examination only once every 45 days. C. An independent examination as often as reasonably required. D. The insured to be examined only within the first 30 days. C. An independent examination as often as reasonably required. While a claim is pending, an insurance company may require an independent exam as often as reasonably required. Which of the following statements is true concerning the alteration of optional policy provisions? A. An insurer may change the wording of optional policy provisions that would adversely affect the policyholder but must first receive state permission before the change goes into effect. B. Once any kind of provision is written, it cannot be changed. C. An insurer may change the wording of optional provisions, as long as the change does not adversely affect the policyholder. D. An insurer may change the wording of optional provisions, regardless of its effect on the policyholder. C. An insurer may change the wording of optional provisions, as long as the change does not adversely affect the policyholder. Optional policy provisions can be changed by an insurer, as long as the changes do not adversely affect the policyholder. If the insured under a disability income insurance policy changes to a more hazardous occupation after the policy has been issued, and a claim is filed, the insurance company should do which of the following? A. Adjust the benefit in accordance with the increased risk B. Cancel the policy C. Increase the premium D. Exclude coverage for on-the-job injury A. Adjust the benefit in accordance with the increased risk A part of the premium rating concerns the hazard of occupation. What is the contract provision that allows the insurer to nonrenew health coverage if certain events occur? A. Conditionally renewable B. Optionally renewable C. Noncancellable D. Guaranteed renewable A. Conditionally renewable The conditionally renewable provision is very similar to the optionally renewable provision. The primary difference is that conditionally renewable policies may be canceled for specific conditions contained in the policy, but optionally renewable policies do not specify a condition or reason for cancellation. When an insured purchased her disability income policy, she misstated her age to the agent. She told the agent that she was 30 years old, when in fact, she was 37. If the policy contains the optional misstatement of age provision A. Because the misstatement occurred more than 2 years ago, it has no effect. B. Amounts payable under the policy will reflect the insured's correct age. C. The contract will be deemed void because of the misstatement of age. D. The elimination period will be extended 6 months for each year of age misstatement. B. Amounts payable under the policy will reflect the insured's correct age. If an insured misstates his or her age upon policy application, the optional misstatement of age provision will change the payable benefit to that which would have been purchased at the insured's actual age. In a group health policy, a probationary period is intended for people who A. Have additional coverage through a spouse. B. Want lower premiums. C. Join the group after the effective date. D. Have a pre-existing condition at the time they join the group. C. Join the group after the effective date. The probationary period is the waiting period new employees must satisfy before becoming eligible for benefits. The provision that states that both the printed contract and a copy of the application form the contract between the policyowner and the insurer is called the A. Certificate of insurance. B. Aleatory contract. C. Master policy. D. Entire contract. D. Entire contract. The policy, together with the attached application, constitutes the entire contract. This provision limits the use of evidence other than the contract and the attached application in a test of the contract's validity. This is a mandatory provision in life insurance. An insured submitted a notice of claim to the insurer, but never received claims forms. He later submits proof of loss, and explains the nature and extent of loss in a hand-written letter to the insurer. Which of the following would be true? A. The claim most likely will not be paid since the official claims form was not submitted. B. The insurer will be fined for not providing the claims forms. C. The insured must submit proof of loss to the Department of Insurance. D. The insured was in compliance with the policy requirements regarding claims. D. The insured was in compliance with the policy requirements regarding claims. If claims forms are not furnished to the insured, the claimant is deemed to have complied with the requirements of the policy if he or she submits written proof of the occurrence, nature of the loss, and extent of loss to the insurer. In the event of loss, after a notice of claim is submitted to the insurer, who is responsible for providing claims forms and to which party? A. Insurer to the insured B. Insured to the insurer C. Insurer to the Department of Insurance D. Insured to the Department of Insurance A. Insurer to the insured Upon receipt of a notice of claim, the company must supply claims forms to the insured within a specified number of days. Which provision allows the policyholder a period of time, while coverage is in force, to examine a health insurance policy and determine whether or not to keep it? A. Probationary Period B. Free Look Period C. Grace Period D. Elimination Period B. Free Look Period The Free Look provision allows a policyholder 10 days after the policy is delivered in which to decide whether or not he/she wants the policy. If the policyholder decides to return the policy within this period, he/she receives a full refund of all premiums paid. If a business owner becomes totally disabled, a Business Overhead Expense policy will pay all of the following EXCEPT A. Loss of the owner's income. B. Rent. C. Utilities. D. Employee payroll. A. Loss of the owner's income. If business owners want coverage for the loss of their own income due to total disability, they need to purchase a separate individual disability income policy. In comparison to a policy that uses the accidental means definition, a policy that uses the accidental bodily injury definition would provide a coverage that is A. More limited in general. B. More limited in duration. C. Broader in duration. D. Broader in general. D. Broader in general. A policy that uses the accidental bodily injury definition will provide broader coverage than a policy An insured wants to buy a disability income policy that pays a maximum monthly benefit of $1,200. To make sure that the disability benefit keeps up with inflation, the insured would need to add A. A guaranteed purchase option rider. B. 5% more to the premium each year. C. An additional monthly benefit rider. D. A cost of living rider. D. A cost of living rider. The cost of living rider is usually tied to the Consumer Price Index (CPI) or another recognized measure of inflation. While repairing the roof of his house an insured accidentally falls off and breaks his arm and sustains a head injury that results in total blindness of both eyes. His policy contains an Accidental Death & Dismemberment Rider. What is the extent of benefits that he will receive? A. Reciprocal Amount B. Principal Sum C. Capital Sum D. 50% of the Principal B. Principal Sum If the insured dies, the insurer pays the full amount, also known as the "principal sum", which is also paid if the insured loses sight in both eyes or loses two limbs. If the insured lives but loses a hand or foot or the sight in one eye, the insured will be paid a percentage of the principal sum, usually 50%, which is called the "capital sum". Your client has a Social Insurance Supplement (SIS) rider on his disability policy. After he becomes disabled, he receives payments from the company. Shortly thereafter, he also begins receiving Social Security benefit payments. Which of the following will happen? A. The SIS rider will discontinue paying benefits. B. Both plans will continue to pay fully. C. The SIS payment will be reduced dollar-for-dollar by the Social Security benefit payment. D. Social Security will discontinue benefits until the SIS rider expires. C. The SIS payment will be reduced dollar-for-dollar by the Social Security benefit payment. A Social Insurance Supplement (SIS) rider pays a disability benefit in an amount close to what Social Security would pay. If Social Security benefit payments begin, the SIS payment will be reduced dollar-for-dollar by the Social Security benefit payment. A policy available to business owners that provides payment for normal business expenses in the event that the owner is disabled is called A. Partial Disability B. Recurrent Disability C. Business Overhead Expense. D. Credit Accident and Health coverage C. Business Overhead Expense. Business Overhead insurance is often purchased by small employers to pay the ongoing business expenses (such as payroll) in the event the owner of the business becomes disabled. Premiums paid are tax deductible as a business expense, but proceeds paid are taxable as income. An insured is involved in an accident that renders him permanently deaf, although he does not sustain any other major injuries. The insured is still able to perform his current job. To what extent will he receive Presumptive Disability benefits? A. Full benefits for 2 years B. No benefits C. Full benefits D. Partial benefits C. Full benefits Presumptive Disability plans offer full benefits for specified conditions. These policies typically require the loss of at least two limbs (Loss of use does not qualify in some policies.), total and permanent blindness, or loss of speech or hearing. Benefits are paid, even if the insured is able to work. An applicant is considered to be high-risk, but not so much that the insurer wants to deny coverage. Which of the following is NOT true? A. The insurer can increase the premium. B. The insurer can add exclusions to the policy. C. The insurer can rate-up the policy. D. The insurer will issue a conditional coverage. D. The insurer will issue a conditional coverage. If an applicant is considered to be too much of a risk, the application can be denied. If, however, the applicant's risks are not high enough to decline, two measures can be taken to protect the insurer: the policy can be rated-up, which means that the premiums will increase, and exclusions can be added, which means that the insurer will not have to cover conditions that make the applicant a high risk to insure. The period of time immediately following a disability during which benefits are not payable is A. The residual period. B. The elimination period. C. The probationary period. D. The grace period. B. The elimination period. The elimination period is a waiting period, expressed in days, not dollars, imposed on the insured from the onset of disability until benefit payments commence. All of the following benefits are available under Social Security EXCEPT A. Death benefits. B. Welfare benefits. C. Old-age and retirement benefits. D. Disability benefits. B. Welfare benefits. Social Security is an entitlement program, not a welfare program. An insured is involved in a car accident. In addition to general, less serious injuries, he permanently loses the use of his leg and is rendered completely blind. The blindness improves a month later. To what extent will he receive Presumptive Disability benefits? A. No benefits B. Full benefits C. Partial benefits D. Full benefits until the blindness lifts A. No benefits Presumptive Disability plans offer full benefits for specified conditions. These policies typically require the loss of use of at least two limbs, total and permanent blindness, or loss of speech or hearing. Benefits are paid, even if the insured is able to work. Because the insured's blindness was only temporary and the loss of use in only 1 leg, he does not qualify for presumptive disability benefits. An insured is covered by a disability income policy that contains an accidental means clause. The insured exits a bus by jumping down the steps and breaks an ankle. What coverage will apply? A. No coverage will apply, since disability income policies cover sickness only. B. Coverage will apply since the break was accidental. C. Coverage will apply, but will be reduced by 50%. D. No coverage will apply, since the injury could have been foreseen D. No coverage will apply, since the injury could have been foreseen An accidental means clause states that if the insured meant to do whatever caused their injury, no coverage applies since the resulting injury should have been foreseen. In disability income insurance, the own occupation definition of disability applies A. As long as an individual is unable to work. B. For the first 2 years of a disability. C. During the waiting period. D. During the elimination period. B. For the first 2 years of a disability. The own occupation definition of disability usually applies to the first 24 months after a loss. Which of the following is considered a presumptive disability under a disability income policy? A. Loss of hearing in one ear B. Loss of one hand or one foot C. Loss of two limbs D. Loss of one eye C. Loss of two limbs Presumptive disability is a provision that is found in most disability income policies that specifies conditions that will automatically qualify the insured for full disability benefits, such as the loss of two limbs. Which statement accurately describes group disability income insurance? A. Short-term plans provide benefits for up to 1 year. B. The extent of benefits is determined by the insured's income. C. In long-term plans, monthly benefits are limited to 75% of the insured's income. D. There are no participation requirements for employees. B. The extent of benefits is determined by the insured's income. Group plans usually specify the benefits based on a percentage of the worker's income. Group long-term plans provide monthly benefits usually limited to 60% of the individual's income. The amount of Social Security disability benefits is based upon the worker's Primary Insurance Amount (PIA), which is calculated from their Average Indexed Monthly Earnings over which years? Which years of income may be deleted from calculation? A. Their highest 20; lowest 2 B. Their highest 35; lowest 5 C. Their highest 40; lowest 5 D. Their highest 15; lowest 4 B. Their highest 35; lowest 5 The amount of Social Security disability benefits is based upon the worker's Primary Insurance Amount (PIA), which is calculated from their Average Indexed Monthly Earnings over their highest 35 years. The lowest 5 years of income may be deleted from calculation. What is the number of credits required for fully insured status for Social Security disability benefits? A. 4 B. 10 C. 30 D. 40 D. 40 The term "fully insured" refers to someone who has earned 40 quarters of coverage (10 years of work times 4 maximum annual credits). An insured is hospitalized with a back injury. Upon checking his disability income policy, he learns that he will not be eligible for benefits for at least 30 days. This would indicate that his policy was probably written with a 30-day A. Probationary period. B. Disability period. C. Elimination period. D. Black-out period. C. Elimination period. The elimination period is the time immediately following the start of a disability when benefits are not payable. This is used to reduce the cost of providing coverage and eliminates the filing of many claims. If a business wants to buy a disability income policy on a key employee, which of the following is considered the applicant? A. The producer B. The employer C. The insurer D. The employee B. The employer In key person disability insurance purchased by a business, the business is the applicant and the key person is the insured. When the policy is issued, the business is the policyowner and is responsible for paying the premiums. Which of the following occupations would have the lowest disability insurance premiums? A. Police officer B. Personal Trainer C. Construction worker D. Stunt pilot B. Personal Trainer The more hazardous an occupation is, the higher the insurance premiums will be. Therefore, because working as a personal trainer poses the least amount of risk, the premiums for this job would be the lowest. An insured has a Social Insurance Supplement rider in her disability income plan. Following a disability, she begins receiving benefit payments from the insurer. She then begins receiving Social Security benefits that are smaller than the SIS benefit payments. At that point, her insurer ends the SIS benefit payments. Which of the following best describes the situation? A. Miscommunication. The proper authorities should be notified in order to end Social Security payments so that the SIS rider will continue to pay. B. Although a mistake may have occurred, the insured has no recourse. C. This is typical of an SIS rider. D. The insured should contact the insurer to confirm her actual Social Security benefit amount. The SIS rider should pay the difference between the rider amount and the actual benefit. D. The insured should contact the insurer to confirm her actual Social Security benefit amount. The SIS rider should pay the difference between the rider amount and the actual benefit. A Social Insurance Supplement (SIS) rider pays a disability benefit in an amount close to what Social Security would pay. If Social Security benefit payments begin, the SIS payment will be reduced dollar-for-dollar by the Social Security benefit payment. Therefore, completely ending SIS payment is illegal. If an insured worker has earned 40 quarters of coverage, the worker's status under Social Security disability is A. Fully insured. B. Partially insured. C. Correctly insured. D. Permanently insured. A. Fully insured. A worker is fully insured under Social Security if the worker has accumulated the required number of credits based on his/her age. On a disability income policy that contains the "own occupation" definition of total disability, the insured will be entitled to benefits if they cannot perform A. Their regular job. B. Any job that they are suited for by prior education. C. Any job that they are suited for by prior training. D. Any job that they are suited for by prior experience. A. Their regular job. If a disability income policy contains the own occupation definition, then the insured will be considered disabled if they cannot perform that particular job, regardless of other jobs that they may be able to do. The rider that may be added to a Disability Income policy that allows for an increase in the benefit amount under certain conditions is called A. Residual Benefits. B. Cost of Living (COLA). C. Waiver of Premium. D. Double Indemnity. B. Cost of Living (COLA). The purchasing power of fixed disability benefits may be eroded due to inflation and increases in the cost of living. This rider is used to protect against these trends by increasing the monthly benefits automatically once the insured has been receiving benefits for 12 months, if the cost of living increases. Which of the following statements regarding Business Overhead Expense policies is NOT true? A. Premiums paid for BOE are tax-deductible. B. Any benefits received are taxable to the business. C. Leased equipment expenses are covered by the plan. D. Benefits are usually limited to six months. D. Benefits are usually limited to six months. Business Overhead Expense (BOE) insurance is sold to small business owners for the purpose of reimbursing the policyholder for business overhead expenses during a period of total disability. Premiums are tax-deductible for a business, but any benefits received are taxable as income. Overhead expenses, including equipment and employee salaries, are covered by the plan. Salaries and profits of the employer are not protected. In order to collect Social Security disability benefits, the claimant must be able to demonstrate that the disability will last at least A. For life. B. 12 months. C. 24 months. D. Until age 65. B. 12 months. Social Security disability benefits are paid to claimants whose disability is expected to last at least 12 months or lead to death. Regarding the taxation of Business Overhead policies, A. Premiums are deductible and benefits are taxed. B. Premiums are not deductible and benefits are taxed. C. Premiums are not deductible, but benefits are deductible. D. Premiums are not deductible, but expenses paid are deductible. A. Premiums are deductible and benefits are taxed. The premiums paid for BOE insurance are tax deductible to the business as a business expense. However, the benefits received are taxable to the business as received. An insured was involved in an accident and could not perform her current job for 3 years. If the insured could reasonably perform another job utilizing similar skills after 1 month, for how long would she be receiving benefits under an "own occupation" disability plan? A. 2 years B. 1 month C. She would not receive any benefits. D. 3 years A. 2 years Under an Own Occupation plan, if the insured cannot perform his/her current job for a period of up to two years, disability benefits will be issued, even if the insured would be capable of performing a similar job during that two-year period. After that, if the insured is capable of performing another job utilizing similar skills, benefits will not be paid. An employee insured under a group health policy is injured in a car wreck while performing her duties for her employer. This results in a long hospitalization period. Which of the following is true? A. The group plan will pay. B. The group plan will pay a portion of the employee's expenses. C. The group plan will pay depending on the employee's recovery. D. The group plan will not pay because the employee was injured at work. D. The group plan will not pay because the employee was injured at work. Because the employee's injuries were work related, the group health policy would not respond. The insured would have to rely on worker's compensation for coverage. What provision can reduce the disability benefit based upon the insured's current income? A. Rehabilitation benefit B. Relation of earnings to insurance C. Waiver of monthly premium D. Pro rata provision B. Relation of earnings to insurance The relation of earnings to insurance provision allows the insurance company to limit the insured's benefits to his/her average income over the last 24 months. All of the following are true regarding key person disability income insurance EXCEPT A. The employer receives the benefits if the key person is disabled. B. The employer pays the premiums. C. The employee is the insured. D. Premiums are tax deductible as a business expense. D. Premiums are tax deductible as a business expense. In key person disability insurance, the contract is owned by the business, the premium is paid by the business, and the business is the beneficiary. The key person is the insured, and the business must have the key person's consent to be insured in writing. In the event of a loss, business overhead insurance will pay for A. Loss of profits. B. Salary of the business owner. C. Medical bills of the business owner. D. Rent. D. Rent. Business overhead insurance is designed to pay the ongoing business expenses of a small business owner while they are disabled and unable to work. It does not pay the salary of the business owner or their loss of profits. However, it will provide the funds needed to pay the salary of employees other than the owners and their other ongoing business expenses, such as rent. Which of the following disability income policies would have the highest premium? A. 15-day waiting period / 5-year benefit period B. 15-day waiting period / 10-year benefit period C. 30-day waiting period / 10-year benefit period D. 30-day waiting period / 5-year benefit period B. 15-day waiting period / 10-year benefit period The waiting, or elimination, period is the time from the onset of disability the insured must wait before becoming eligible for benefits. The shorter the waiting period, the higher the premium. After the insured satisfies the waiting period, they will receive benefits from the insurer for a limited benefit period. The longer the benefit period, the higher the premium. A disability income policy that includes the shortest waiting period and the longest benefit period would be most expensive. A business wants to make sure that if a key employee becomes disabled, the business will be protected from any resulting loss. Which kind of insurance will protect the business? A. Management Loss B. Business Loss C. Business Disability D. Individual Disability C. Business Disability A business can purchase Business Disability Insurance in order to protect itself from losses resulting from the disability of key employees. An insured's disability income policy includes an additional monthly benefit rider. For how many years can the insured expect to receive payment from the insurer before Social Security benefits begin? A. 5 B. 3 C. 2 D. 1 D. 1 The additional monthly benefit rider stipulates that the insurer will pay benefits comparable to what Social Security would pay. After a year, the insurer ends the benefit and assumes that Social Security will begin benefit payment. Social Security was created to protect against all of the following EXCEPT A. Sickness in old age. B. Premature death. C. Disability. D. Bad investment choices. D. Bad investment choices. Social Security is a Federal program enacted in 1935, that is designed to provide protection, for eligible workers and their dependents, against financial loss due to death, disability, superannuation (retirement income), and sickness in old age. The minimum number of credits required for partially insured status for Social Security disability benefits is A. 4 credits. B. 6 credits. C. 10 credits. D. 40 credits. B. 6 credits. To be considered partially insured, an individual must have earned 6 credits during the last 13-quarter period. Disability income policies can provide coverage for a loss of income when returning to work only part-time after recovering from total disability. What is the benefit that is based on the insured's loss of earnings after recovery from a disability? A. Recurrent disability B. Partial disability C. Income replacement D. Residual disability D. Residual disability A residual disability will pay an amount to make up the difference between what the insured would have earned before the loss. Certain conditions, such as dismemberment or total and permanent blindness, will automatically qualify the insured for full disability benefits. Which disability policy provision does this describe? A. Residual disability B. Presumptive disability C. Dismemberment disability D. Partial disability B. Presumptive disability Presumptive disability is a provision that is found in most disability income policies which specifies the conditions that will automatically qualify the insured for full disability benefits.
In a disability policy, the elimination (or waiting) period refers to the period between A. The effective date of the policy and the date the first premium is due. B. Coverage under a disability policy and coverage under Social Security. C. During which any specific illness or accident is excluded from coverage. D. The first day of disability and the day the insured starts receiving benefits. D. The first day of disability and the day the insured starts receiving benefits. The elimination, or waiting, period starts at the onset of a disability claim and is the period of time the insured must wait before benefits start. What is the purpose of the rehabilitation benefit in disability insurance? A. To cover the expenses of retraining the insured to return to work B. To compensate the insured for the lost income C. To refund the insured's premium paid during the disability D. To help the insured recover from a disability A. To cover the expenses of retraining the insured to return to work The rehabilitation benefit will cover a portion of the cost for the insured to enroll in a retraining program that will help the insured to return to work after a disability. Underwriting for disability insurance is unique due to the type of risk involved. Which of the following situations illustrates this? A. A construction worker pays a higher premium and receives a poorer classification of disability. B. A stunt person pays a low premium and receives a superior classification of disability. C. An attorney pays a higher premium and receives a poorer classification of disability. D. A secretary pays a higher premium and receives a superior classification of disability. A. A construction worker pays a higher premium and receives a poorer classification of disability. In disability income policies, the insured's occupation is a critical underwriting factor. The more hazardous the applicant's occupation, the higher the premium the insurance company will charge. To attain currently insured status under Social Security, a worker must have earned at least how many credits during the last 13 quarters? A. 4 credits B. 6 credits C. 10 credits D. 40 credits B. 6 credits To be considered currently (or partially) insured, an individual must have earned 6 credits during the last 13-quarter period. Bethany studies in England for a semester. While she is there, she is involved in a train accident that leaves her disabled. If Bethany owns a general disability policy, what will be the extent of benefits that she receives? A. Full B. 50% C. 25% D. None D. None General disability policies do not cover losses caused by war, military service, intentionally self-inflicted injuries, overseas residence, or injuries suffered while committing or attempting to commit a felony. Which of the following are the main factors taken into account when calculating residual disability benefits? A. Employee's full-time status and length of disability B. Present earnings and standard cost of living C. Present earnings and earnings prior to disability D. Earnings prior to disability and the length of disability C. Present earnings and earnings prior to disability Residual disability will help pay for loss of earnings by making up the difference between the employee's present earnings and what they were earning prior to disability. In disability income insurance, if an insured is considered disabled if they cannot perform any job they are suited for by prior education, training or experience, they fall under which definition of total disability? A. Typical B. Statutory C. Own occupation D. Any occupation D. Any occupation For disability income benefits to be paid, the insured must whatever definition of total disability is stated in the policy, which varies. The "any occupation" definition states that an insured is disabled if they cannot perform any job that they are suited for by prior education, training or experience. The "own occupation" definition states that an insured is disabled if they cannot perform their own job, whatever that may be. Any occupation disability typically means that an individual is unable to perform the duties of the occupation for which he/she is suited by all of these EXCEPT A. Experience. B. Preference. C. Education. D. Training. B. Preference. By definition used by most insurers, any occupation disability typically means that an individual is unable to perform the duties of the occupation for which he/she is suited by education, training, and experience. When an insurer combines two periods of disability into one, the insured must have suffered a A. Recurrent disability. B. Partial disability. C. Residual disability. D. Presumptive disability. A. Recurrent disability. Recurrent disability is the period of time (usually within 3-6 months) during which the recurrence of an injury or illness will be considered as a continuation of a prior period of disability. A Waiver of Premium provision may be included with which kind of health insurance policy? A. Dread Disease B. Disability Income C. Basic medical D. Hospital indemnity B. Disability Income A Waiver of Premium rider generally is included with guaranteed renewable and noncancellable individual disability income policies. It is a valuable provision because it exempts the insured from paying the policy's premium during periods of total disability. Which of the following is NOT a characteristic of a group long-term disability plan? A. The benefit can be up to 50% of one's yearly income. B. The elimination period is the same as in the short-term plan's benefit period. C. The benefit period may be to age 65. D. The benefit can be up to 66 and 2/3% of one's monthly income. A. The benefit can be up to 50% of one's yearly income. The maximum benefit is based upon monthly income. If an individual is covered by a policy that includes an Accidental Death & Dismemberment rider, what term describes the maximum benefits he will receive if he loses sight in both eyes as a result of a fire? A. Reciprocal amount B. Capital sum C. Percentage of full amount D. Principal sum D. Principal sum If the insured dies, the insurer pays the full amount, also known as the "principal sum". Principal sum will most likely be paid out if the insured loses sight in both eyes or loses two limbs. If the insured lives but loses a hand or foot or the sight in one eye, the insured will be paid a percentage of the principal sum, called the "capital sum." How is the amount of Social Security disability benefits calculated? A. It is based on age, number of quarters worked in the last 20 years (minimum of 60) and the number of health claims made during that period of time. B. It is based upon the worker's Primary Insurance Amount (PIA), which is calculated from their Average Indexed Monthly Earnings over their highest 35 years. C. It is based upon the worker's Primary Insurance Amount (PIA), which is calculated from their Average Indexed Monthly Earnings over their highest 30 years. D. It is based on age, number of quarters worked in the last 25 years (minimum of 80) and the number of health claims made during that period of time. B. It is based upon the worker's Primary Insurance Amount (PIA), which is calculated from their Average Indexed Monthly Earnings over their highest 35 years. The amount of Social Security disability benefits is based upon the worker's Primary Insurance Amount (PIA), which is calculated from their Average Indexed Monthly Earnings over their highest 35 years. The lowest 5 years of income may be deleted from calculation. When does a person qualify to receive disability-related income? A. When an insured is hospitalized for more than one week B. When the insured is unable to perform his/her job duties C. When the disability reaches a designated state of severity D. When an injury is severe and the insured is not a dependent B. When the insured is unable to perform his/her job duties A person must be unable to perform his/her occupation in order to be eligible for disability income benefits. All of the following are true about group disability Income insurance EXCEPT A. Benefits are usually short term. B. The waiting period starts at the onset of the injury or sickness. C. The longer the waiting period, the lower the premium. D. Coverage applies both on and off the job. D. Coverage applies both on and off the job. Employees who are injured on the job are covered by Workers Compensation insurance. Group Disability Income insurance is designed to cover employees only while they are off the job, so the coverage is considered to be nonoccupational in nature. A small business owner is the insured under a disability policy that funds a buy-sell agreement. If the owner dies or becomes disabled, the policy would provide which of the following? A. Cash to the owner's business partner to accomplish a buyout B. The rent money for the building C. The business manager's salary D. Disability insurance for the owner A. Cash to the owner's business partner to accomplish a buyout If an owner dies or becomes disabled, the disability policy under the buy-sell agreement would provide enough cash to accomplish a buyout of the company. Which of the following is an eligibility requirement for all Social Security Disability Income benefits? A. Be at least age 50 B. Have attained fully insured status C. Be disabled for at least 1 year D. Have permanent kidney failure B. Have attained fully insured status Although Social Security offers many benefits, such as retirement, survivors and Medicare, only those who have attained fully insured status are eligible for Disability Income benefits. Contributing to Social Security for 40 quarters (10 years) attains fully insured status. Which of the following conditions would a disability income policy most likely NOT require in order to qualify for benefits? A. The insured must provide proof of disability B. A specified income status prior to the disability C. The insured must be under a physician's care D. The insured must be confined to the house B. A specified income status prior to the disability Some Disability Income policies require that the insured must be under the care of a physician and possibly confined to his/her house in order to be eligible for disability benefits. Even though disability income benefits are limited to a percentage of earned income, to qualify for benefits, a person must meet the disability definition. A man's physician submits claim information to his insurer before she actually performs a medical procedure on him. She is doing this to see if the procedure is covered under the patient's insurance plan and for how much. This is an example of A. Prospective review. B. Concurrent review. C. Claims-delayed treatment. D. Suspended treatment. A. Prospective review. Under the prospective review or precertification provision, the physician can submit claim information prior to providing treatment to know in advance if the procedure is covered under the insured's plan and at what rate it will be paid. Which of the following is NOT true of basic medical expense plans? A. No deductibles B. First-dollar coverage C. Low dollar limits D. Coverage for catastrophic medical expenses D. Coverage for catastrophic medical expenses Basic medical expense plans were characterized by first-dollar coverage (no deductible) and low dollar limits, which meant they afforded no protection to an individual or family against catastrophic medical expenses that could be financially disastrous. All of the following are ways in which a Major Medical policy premium is determined EXCEPT A. The average age of the group. B. The amount of the deductible. C. The coinsurance percentage. D. The stop-loss amount. A. The average age of the group. Major medical policy premiums vary depending on the amount of the deductible, the coinsurance percentage, the stop-loss amount and the maximum amount of the benefit. What is a penalty tax for nonqualified distributions from a health savings account? A. 8% B. 10% C.12% D. 20% D. 20% An HSA holder who uses the money for a nonhealth expenditure pays tax on it, plus a 20% penalty Which of the following would NOT be used in preventive care? A. Pap smear B. Annual physical exam C. Mammogram D. Chemotherapy D. Chemotherapy Managed care plans encourage preventive care and living a healthier lifestyle. Annual physical exams, mammograms, and other procedures used to detect medical problems before symptoms appear can result in a considerable cost savings if a problem is detected early and treated quickly. A medical insurance plan in which the health care provider is paid a regular fixed amount for providing care to the insured and does not receive additional amounts of compensation dependent upon the procedure performed is called A. Reimbursement plan. B. Fee-for-service plan. C. Prepaid plan. D. Indemnity plan. C. Prepaid plan. Under a prepaid plan, the health care providers are paid for services in advance, whether or not any services are provided. The amount paid to the provider is based upon the projected annual cost as determined by the provider. An insured has a major medical policy with a $500 deductible and 80/20 coinsurance. The insured is hospitalized and sustains a $2,500 bill. What is the maximum amount that the insured will have to pay? A. $500 B. $900 C. $1,000 D. $2,500 B. $900 The insured will pay the $500 deductible, plus 20% of the remainder: $2,500 (total bill) - $500 (deductible) = $2,000; 20% of $2,000 = $400; $500 (deductible) + 20% (coinsurance) = $900 (total amount due by the insured). As deductible amounts increase, premium amounts change in what way? A. Decrease B. Increase C. Remain the same. Changes in premium amounts do not affect deductible amounts. D. Either increase or decrease. A. Decrease If deductibles increase, premiums decrease in response. In other words, if the insured assumes more risk by paying a higher deductible, the insurer will lower premium amounts in response. Which of the following are responsible for making premium payments in an HMO plan? A. Payors B. Subscribers C. Producers D. Insureds B. Subscribers Subscribers are people in whose name the contract is issued. They would be responsible for making premium payments. Which of the following would be a typical maximum benefit offered by major medical plans? A. $10 million B. $50,000 C. $500,000 D. $1 million D. $1 million Major medical plans have high maximum benefits such as $1,000,000 or $2,000,000. Maximum benefits are usually lifetime maximums. Which of the following is NOT the purpose of HIPAA? A. To limit exclusions for pre-existing conditions B. To provide immediate coverage to new employees who had been previously covered for 18 months C. To guarantee the right to buy individual policies to eligible individuals D. To prohibit discrimination against employees based on their health status B. To provide immediate coverage to new employees who had been previously covered for 18 months HIPAA does not prohibit employers or providers from establishing waiting periods or pre-existing conditions exclusions, in which case the coverage to new employees would not be immediate. An employee becomes insured under a PPO plan provided by his employer. If the insured decides to go to a physician who is not a PPO provider, which of the following will happen? A. The PPO will pay reduced benefits. B. The PPO will not pay any benefits at all. C. The insured will be required to pay a higher deductible. D. The PPO will pay the same benefits as if the insured had seen a PPO physician. A. The PPO will pay reduced benefits. The group health plan will not pay the full amount charged by the non-PPO doctor. Which of the following is the term for the specific dollar amount that must be paid by an HMO member for a service? A. Cost share B. Copayment C. Deductible D. Premium B. Copayment A copayment is a specific dollar amount of the cost of care that must be paid by the member. For example, the member may be required to pay $5 or $10 for each office visit. Which of the following is NOT a metal level of coverage offered under the Patient Protection and Affordable Care Act? A. Silver B. Bronze C. Iron D. Gold C. Iron The metal tiers of coverage required under the PPACA include platinum, gold, silver and bronze. At what age may an individual make withdrawals from an HSA for nonhealth purposes without being penalized? A. 55 B. 59 1/2 C. 62 D. 65 D. 65 After age 65, a withdrawal from an HSA used for a nonhealth purposes will be without a penalty, although taxed. Which of the following statements is NOT correct concerning the COBRA Act of 1985? A. It applies only to employers with 20 or more employees that maintain group health insurance plans for employees. B. COBRA stands for Consolidated Omnibus Budget Reconciliation Act. C. It requires all employers, regardless of the number or age of employees, to provide extended group health coverage. D. It covers terminated employees and/or their dependents for up to 36 months after a qualifying event.
C. It requires all employers, regardless of the number or age of employees, to provide extended group health coverage. COBRA Act applies to only employers with 20 or more employees. If an employee terminates her employment, which of the following provisions would allow her to continue health coverage under an individual policy, if requested within 31 days? A. Conversion B. Replacement C. Grace period D. Renewability A. Conversion Conversion provisions are required by law. It allows terminated employees to convert their group health coverage to individual insurance without evidence of insurability, within a specified amount of time, and for eligible reasons. Which of the following would be a qualifying event as it relates to COBRA? A. Eligibility for Medicare B. Termination of employment due to downsizing C. Termination of employment for stealing D. Eligibility for coverage under another group plan B. Termination of employment due to downsizing Employee qualifying events include the termination of employment for reasons other than for misconduct; dependents' qualifying events include the death of the employee, divorce or legal separation. A group blanket health policy is best suited for which of the following? A. A small employer B. A manufacturer C. A large family D. A summer camp D. A summer camp Group blanket health insurance policies are meant to cover members of a group or association without evidence of insurability. Coverage is usually limited to loss from specific causes. All of the following statements describe a MEWA EXCEPT A. MEWAs can be sponsored by insurance companies. B. MEWA employers retain full responsibility for any unpaid claims. C. MEWAs can be self-insured. D. MEWAs are groups of at least 3 employers. D. MEWAs are groups of at least 3 employers. MEWAs are groups of at least 2 employers who pool their risks to self-insure. MEWAs can be sponsored by an insurance company, an independent administrator, or another group established to provide group benefits for participants. Which of the following is true regarding METs? A. They provide insurance for larger corporations. B. They provide insurance companies with medical information on applicants. C. They allow several small employers purchase less expensive insurance together. D. They make deals with local hospitals to provide low cost coverage to the needy. C. They allow several small employers purchase less expensive insurance together. Those small employers who cannot qualify for group health insurance band together for the purpose of buying insurance. What is the benefit of experience rating? A. It allows employers with high claims experience to obtain insurance. B. It allows employers with low claims experience to get lower premiums. C. It helps employers with high claims experience to get group coverage. D. It helps employees with low claims experience to become exempt from group premiums. B. It allows employers with low claims experience to get lower premiums. Group health insurance is usually subject to experience rating where the premiums are determined by the experience of this particular group as a whole. Experience rating helps employers with low claims experience because they get lower premiums.
Which of the following groups would probably be covered by blanket insurance? A. People who obtain temporary insurance B. A university's sports team C. A large family D. A publishing company B. A university's sports team A blanket policy covers members of a particular group when they are participating in a particular activity. Such groups include students, campers, passengers on a common carrier, or sports teams. Often the covered individual's name is not known because individuals come and go. Unlike group health insurance the individuals are automatically covered, and they do not receive a certificate of insurance. Which of the following options best depicts how the eligibility of members for group health insurance is determined? A. By the physical conditions of the applicants at the time of employment B. In such a manner as to establish individual selection as to the amounts of insurance C. By conditions of employment D. Eligibility is not determined, but simply accepted C. By conditions of employment The individual employer normally must provide insurance coverage to all full-time employees. The employer can specify within some limitations how many hours are considered full time, and whether both salaried and hourly employees will be covered. The employer can also legally exclude a particular group of employees from the eligible class of employees. Kevin and Nancy are married; Kevin is the primary breadwinner and has a health insurance policy that covers both him and his wife. Nancy has an illness that requires significant medical attention. Kevin and Nancy decide to legally separate, which means that Nancy will no longer be eligible for health insurance coverage under Kevin. Which of the following options would be best for Nancy at this point? A. Convert to an individual insurance policy with 31 days so she won't have to provide evidence of insurability B. COBRA C. Apply for social security benefits D. Apply for coverage under the same group policy that covers Kevin B. COBRA Dependents of employees are eligible to receive group health insurance under the employee's plan. If the employee and the dependent become legally separated or divorced, or if the employee dies, the dependent will be eligible for COBRA benefits for up to 36 months. This is best for Nancy, since she has endured a long-term illness. Otherwise, being approved for individual health insurance would be difficult. What is the period of coverage for events such as death or divorce under COBRA? A. 36 months B. 60 days C. 31 days D. 12 months A. 36 months The maximum period of coverage under COBRA is 36 months, in the event of the covered employee's death or divorce. After a person's employment is terminated, it is possible to obtain individual health insurance after losing the group health coverage provided by the employer. Which of the following is NOT true? A. The employee can convert from group to individual insurance within 31 days of termination. B. The premium of the individual health insurance policy can be higher than the original policy. C. By law, the new, individual policy must provide the same benefits as the group insurance policy. D. Continuation of group coverage need not include dental, vision, or prescription drug benefits. C. By law, the new, individual policy must provide the same benefits as the group insurance policy. Terminated employees have 31 days to convert to an individual health insurance policy, without having to provide proof of insurability. The insurer can adjust the new, individual health policy's premium as it sees fit, as long as coverage is provided. The new policy could offer lesser benefits than the original group health policy. Why do group health providers usually require a certain amount of participation in the plan by eligible employees? A. To ensure a higher profit for the insurer B. To ensure the employer is being fair to employees C. To guard against adverse selection and reduce cost D. To promote preventive care C. To guard against adverse selection and reduce cost The reason for the minimum participation requirement is to guard against adverse selection and to reduce administrative costs for the insurer. A 55-year-old employee has worked part-time for his new employer for 3 months now, but has not been offered health insurance. What factor has limited the employee's eligibility? A. The total amount of time worked for the company B. Age C. Income D. Number of hours worked per week D. Number of hours worked per week In order to be eligible for group health insurance through an employer, an employee must typically work full-time and must have devoted one to three months of service. In this case, the employee has been with the employer long enough, but he does not work enough hours per week. An association could buy group insurance for its members if it meets all of the following requirements EXCEPT A. Is contributory. B. Has at least 50 members. C. Has a constitution and by-laws. D. Holds annual meetings. B. Has at least 50 members. All of the above characteristics would make an association group eligible for buying group insurance, except the group must have at least 100 members. In a group policy, who is issued a certificate of insurance? A. The health care provider B. The insurance company C. The employer D. The individual insured D. The individual insured The individuals covered under a group insurance contract are issued certificates of insurance. The certificate tells what is covered in the policy, how to file a claim, how long the coverage will last, and how to convert the policy to an individual policy. The First Street Church plans to sponsor a summer camp for the youth of their congregation. They would like to purchase insurance that would pay benefits should one of the youth get injured while participating in the camp activities. The type of policy they would likely need is a/an A. Blanket. B. Limited Sickness. C. Accidental Death and Dismemberment. D. Limited Accident. A. Blanket. A policy that covers all of the participants without naming them individually is a blanket policy. In group insurance, what is the policy called? A. Master policy B. Entire contract C. Certificate of authority D. Certificate of insurance A. Master policy In group insurance the policy is called the master policy and is issued to the policyowner, which could be the employer, an association, a union, or a trust. Which of the following factors would be an underwriting consideration for a small employer carrier? A. Medical history of the employees B. Percentage of participation C. Claims experience D. Health status
B. Percentage of participation Coverage under a small employer health benefit plan is generally available only if at least 75% of eligible employees elect to be covered. Jason is insured under his employer's group health insurance. He splits the cost of the premiums with his employer. This is an example of A. A half and half plan. B. A co-pay plan. C. A contributory plan. D. A noncontributory plan. C. A contributory plan. With a contributory plan the eligible employees contribute to payment of the premium (both the employee and employer pay part of the premium). Which of the following groups would most likely be covered under a blanket accident policy? A. Independent contractors who work for a general contractor B. Students at a public school C. Office workers for a retail business D. Factory workers at the automobile assembly plant B. Students at a public school Blanket insurance is issued on those groups that have members that are constantly changing. What type of information is NOT included in a certificate of insurance? A. The length of coverage B. The cost the company is paying for monthly premiums C. The policy benefits and exclusions D. The procedures for filing a claim B. The cost the company is paying for monthly premiums The individuals covered under the insurance contract are issued certificates of insurance. The certificate tells what is covered in the policy, how to file a claim, how long the coverage will last, and how to convert the policy to an individual policy. In instances where a coordination of benefits provision is necessary, and two relevant plans cannot agree on the order of benefits, they have to pay the claim in equal shares. How long do they have to determine the order of benefits? A. 60 B. 90 C. 7 D. 30 D. 30 In this situation, the insurers have 30 days to determine the order of benefits. A husband and wife are insured under group health insurance plans at their own places of employment, and as dependents under their spouse's coverage. If one of them incurs hospital expenses, how will those expenses likely be paid? A. The benefits will be coordinated. B. Neither plan would pay. C. Each plan will pay in equal shares. D. The insured will have to select a plan from which to collect benefits. A. The benefits will be coordinated. Benefits will be coordinated when individuals are covered under two or more health plans. Andy and Amy, both 53 years of age, are married. Amy is covered under Andy's family health insurance plan at work. If Andy dies unexpectedly, which of the following is true regarding Amy's health coverage? A. Amy will be given the option to continue her coverage under the group plan, but will have to pay premiums for her coverage. B. Amy will be given the option to continue her coverage under the group plan, and will not have to pay premiums for her coverage. C. The group coverage will terminate 90 days after Andy's death. Amy will now have to buy an individual policy and provide evidence of insurability. D. The group coverage will terminate 90 days after Andy's death. Amy will now have to buy an individual policy, but will not have to provide evidence of insurability. A. Amy will be given the option to continue her coverage under the group plan, but will have to pay premiums for her coverage. If a group member dies, the surviving spouse must be given the choice of continuing coverage under the group plan. The coverage must be the same. The group policyholder will be in charge of collecting the required premium from the surviving spouse. A group policy used to provide accident and health coverage on a group of persons being transported by a common carrier, without naming the insured persons individually is called A. Blanket Policy. B. Activity policy. C. Specified disease policy. D. Certificate of Coverage Policy. A. Blanket Policy. A single policy covering several certificate holders without naming the insured individually is a blanket policy. One of the differences between group underwriting and individual underwriting is that there is little or no medical information required regarding plan participants in groups of A. 25 or more. B. Fewer than 50. C. 50 or more. D. 100 or more. C. 50 or more. In groups of 50 or more, medical information cannot be required of plan participants. In a group policy, the contract is between A. The employee and the employer. B. The employer and the insurance company. C. The individual and the insurance company. D. The employer and the union. B. The employer and the insurance company. In a group policy, the contract is between the insurance company and the group sponsor (such as employer, union, trust, or other sponsoring organization). What type of group rating uses the actual experience of the group as a factor in developing the rates to be charged? A. Experience rating B. District rating C. Community rating D. Individual rating A. Experience rating The actual loss experience of the group, in part, determines the rates charged by the insurer. An insured has mistakenly failed to enroll in her husband's health plan. What would happen following a major health expense? A. Her husband's insurance would pay up to its limit B. Her insurance would become primary, and her husband's secondary C. Her insurance would pay up to its limit D. Her insurance and her husband's insurance would share the cost on a pro rata basis C. Her insurance would pay up to its limit In this situation, the insured would not be eligible for the coordination of benefits provision. Therefore, her insurance would pay up to its limit. What is the period of coverage for events such as death or divorce under COBRA? A. 60 days B. 31 days C. 12 months D. 36 months D. 36 months The maximum period of coverage under COBRA is 36 months, in the event of the covered employee's death or divorce. As it pertains to group health insurance, COBRA stipulates that A. Terminated employees must be allowed to convert their group coverage to individual policies. B. Group coverage must be extended for terminated employees up to a certain period of time at the employer's expense. C. Group coverage must be extended for terminated employees up to a certain period of time at the former employee's expense. D. Retiring employees must be allowed to convert their group coverage to individual policies. C. Group coverage must be extended for terminated employees up to a certain period of time at the former employee's expense. COBRA requires employers with 20 or more employees to continue group medical insurance for terminated workers and dependents for up to 18 months to 36 months. The employee can be required to pay up to 102% of the coverage's premium. Can a group that is formed for the sole purpose of obtaining group insurance qualify for group coverage? A. No, a group of individuals cannot apply for group coverage unless represented by an association or trust. B. Yes, any group can apply for group coverage. C. Yes, but only if the group is over 35 people. D. No, the group must be formed for a purpose other than obtaining group insurance. D. No, the group must be formed for a purpose other than obtaining group insurance. In order to qualify for group coverage, the group must be formed for a purpose other than obtaining group insurance; the coverage must be incidental to the group. An insured has a primary group health plan and an excess plan, each covering losses up to $10,000. The insured suffered a loss of $15,000. Disregarding any copayments or deductibles, how much will the excess plan pay? A. $10,000 B. $7,500 C. $5,000 D. $0 C. $5,000 Once the primary plan has paid its full promised benefit, the insured submits the claim to the secondary, or excess, provider for any additional benefits payable. Which statement best defines a Multiple Employer Welfare Arrangement (MEWA)? A. A plan that provides hospice care for terminally ill employees B. A government health plan that provides health care for the unemployed C. A group health plan that covers medical expenses arising from work related injuries D. A joining together by employers to provide health benefits for employee D. A joining together by employers to provide health benefits for employee A MEWA provides benefits for a number of member groups. COBRA applies to employers with at least A. 60 employees. B. 50 employees. C. 20 employees. D. 80 employees. C. 20 employees. Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), any employer with 20 or more employees must extend group health coverage to terminated employees and their families. Which of the following long-term care benefits would provide coverage for care for functionally impaired adults on a less than 24-hour basis? A. Residential care B. Assisted living C. Home health care D. Adult day care D. Adult day care Adult day care is designed for those who require assistance with various ADLs on a daily basis, but not around the clock. Custodial care is usually the only service provided by adult day care facilities. Medicaid provides all of the following benefits EXCEPT A. Family planning services. B. Income assistance for work-related injury. C. Home health care services. D. Eyeglasses. B. Income assistance for work-related injury. Medicaid covers a variety of medical costs, from eyeglasses to hospitalization. Which of the following statements is correct? A. HMOs do not pay for services covered by Medicare. B. Medicare Advantage is Medicare provided by an approved Health Maintenance Organization only. C. All HMOs and PPOs charge premiums beyond what is paid by Medicare. D. HMOs may pay for services not covered by Medicare. D. HMOs may pay for services not covered by Medicare. The advantages of an HMO or PPO for a Medicare recipient may be that there are no claims forms required, almost any medical problem is covered for a set fee so health care costs can be budgeted, and the HMO or PPO may pay for services not usually covered by Medicare or Medicare supplement policies, such as prescriptions, eye exams, hearing aids, or dental care. Which of the following is NOT an activity of daily living (ADL)? A. Talking B. Eating C. Dressing D. Bathing A. Talking The ability of a person to do activities of daily living (ADLs) is often used to determine the extent of a person's disability. ADLs include basic activities such as getting dressed, bathing, continence, transferring, and eating. What is the difference between the Medicare approved amount for a service or supply and the actual charge? A. Excess charge B. Actual charge C. Limiting charge D. Coinsurance A. Excess charge Excess Charge is the difference between the Medicare approved amount for a service or supply and the actual charge. Which of the following Medicare supplement plans would be available to a reasonably healthy 91-year-old female? A. K & L only B. A only C. A-C only D. A-N D. A-N All Medicare supplement plans (A-N) must be made available to qualifying applicants, regardless of age. For how many days of skilled nursing facility care will Medicare pay benefits? A. 60 B. 90 C. 100 D. 30 C. 100 Treatment in a skilled nursing facility is covered in full for the first 20 days. From the 21st to the 100th day, the patient must pay the daily copayment. There are no Medicare benefits provided for treatment in a skilled nursing facility beyond 100 days. Regarding long-term care coverage, as the elimination period gets shorter, the premium A. Gets lower. B. Gets higher. C. Remains constant. D. Premiums are not based on elimination periods. B. Gets higher. LTC policies also define the benefit period for how long coverage applies, after the elimination period. The benefit period is usually 2 to 5 years, with a few policies offering lifetime coverage. Obviously the longer the benefit period, the higher the premium will be; and the shorter the elimination period, the higher the premium will be. All of the following statements about Medicare supplement insurance policies are correct EXCEPT A. They cover Medicare deductibles and copayments. B. They supplement Medicare benefits. C. They are issued by private insurers. D. They cover the cost of extended nursing home care. D. They cover the cost of extended nursing home care. Medicare supplement policies (Medigap) do not cover the cost of extended nursing home care. Medigap plans are designed to fill the gap in coverage attributable to Medicare's deductibles, copayment requirements, and benefit periods. These plans are issued by private insurance companies. Which of the following programs is made up of 4 parts, where the first part is paid for by FICA, and the second part is financed by premiums and payroll taxes? A. Medicare B. Blue Cross C. Blue Shield D. Medicaid A. Medicare Medicare has four parts: A, B, C and D. Part A, Hospital Insurance, is financed through a portion of the payroll tax (FICA). Part B, Medical Insurance, is financed from monthly premiums paid by insureds and from the general revenues of the federal government. Part C allows people to receive all of their health care services through available provider organizations, and Part D is for prescription drug coverage. Following an injury, a policyowner covered under Medicare Parts A & B was treated by her physician on an outpatient basis. How much of her doctor's bill will she be required to pay out-of-pocket? A. 80% of covered charges above the deductible B. All reasonable charges above the deductible according to Medicare standards C. A per office visit deductible D. 20% of covered charges above the deductible D. 20% of covered charges above the deductible After the deductible, Part B will pay 80% of covered expenses, subject to Medicare's standards for reasonable charges. In which Medicare supplemental policies are the core benefits found? A. Plans A-D only B. All plans C. Plans A and B only D. Plan A only B. All plans The benefits in Plan A are considered to be core benefits and must be included in the other types. Therefore, all types contain the core benefits offered by Plan A. The Omnibus Budget Reconciliation Act of 1990 requires that large group health plans must provide primary coverage for disabled individuals under A. Age 59½ who are retired. B. Age 65 who are not retired. C. Age 59½ who are not retired. D. Age 65 who are retired. B. Age 65 who are not retired. The Omnibus Budget Reconciliation Act of 1990 requires that large group health plans (100 employees or more) must provide primary coverage for disabled individuals under age 65 who are not retired. A long-term care shopper's guide must be presented at what point? A. Prior to the time of application B. At the time of application C. Between the completion of the application and the delivery of the policy D. At the time of policy delivery A. Prior to the time of application A long-term care insurance shopper's guide must be provided in the format developed by the National Association of Insurance Commissioners (NAIC). The shopper's guide must be presented to the applicant prior to completing the application. Which of the following provisions must be included on the first page of a Medicare supplement policy, which states the insurer's right to change premium amounts? A. Premium provision B. Insurer's rights C. Coverage limitations D. Continuation provision D. Continuation provision The renewal provision, also known as a continuation provision, must be included on the first page of Medicare supplement policies. This provision explains the right of the insurer to alter premium amounts. Occasional visits by which of the following medical professionals will NOT be covered under LTC's home health care? A. Attending physician B. Registered nurses C. Licensed practical nurses D. Community-based organization professionals A. Attending physician Home health care is care provided in one's home and could include occasional visits to the person's home by registered nurses, licensed practical nurses, licensed vocational nurses, or community-based organizations like hospice. Home health care might include physical therapy and some custodial care such as meal preparations.
The gatekeepers provision determines eligibility for benefits based upon A. A physician's assessment. B. Financial need. C. Ability to perform ADLs. D. Benefit history. C. Ability to perform ADLs. Long Term Care policies include a gatekeepers provision, which determines a person's eligibility for benefits based upon his/her ability to perform activities of daily living (ADLs).
An insured has Medicare Part D coverage. He has reached his initial benefit limit and must now pay 50% of his prescription drug costs. What is the term for this gap in coverage? A. Bridge B. Blackout period C. Latency period D. Donut hole D. Donut hole Once the initial benefit limit is reached, a gap called a "donut hole" occurs, in which the beneficiary is responsible for a portion of prescription drug costs. Which of the following statements is NOT correct? A. Medicare Part B provides physician services. B. Medicare Advantage must be provided through HMOs. C. Medicare Advantage may include prescription drug coverage at no cost D. Medicare Part A provides hospital care. B. Medicare Advantage must be provided through HMOs. Medicare Part A provides hospital care; Medicare Part B provides doctors and physician services, and Medicare Advantage (previously Medicare+Choice) offers expanded benefits for a fee through private health insurance programs such as HMOs and PPOs. If one takes Social Security retirement benefits at age 62, what needs to be done at age 65 to qualify for Medicare? A. Apply for coverage through the state B. Appear for a physical at the Social Security office C. Apply at a local Social Security office D. Nothing D. Nothing Nothing needs to be done in this case. Medicare Part A and B will automatically be effective the month you turn 65. When can a Long-Term Care policy deny a claim for losses incurred because of a pre-existing condition? A. At no time B. Within 6 months of the effective date of coverage C. Within 12 months of the effective date of coverage D. At any time B. Within 6 months of the effective date of coverage A long-term care policy cannot deny a claim for losses incurred more than 6 months from the effective date of coverage because of a pre-existing condition. According to OBRA, what is the minimum number of employees required to constitute a large group? A. 100 B. 15 C. 20 D. 50 A. 100 There must be at least 100 employees in order to qualify for OBRA large-group status. The act states that plans must provide primary coverage for disabled individuals under age 65 who are not retired. OBRA requires which disease to be covered by an employer for 30 months before Medicare becomes the primary mode of coverage? A. End-stage renal failure B. Black lung C. Leukemia D. End-stage heart failure A. End-stage renal failure OBRA requires end-stage kidney (renal) failure to be covered by an employer for 30 months before Medicare becomes the primary mode of coverage. Prior to issuance of a Long-Term Care policy to an applicant age 80 or older, the insurer must obtain all of the following EXCEPT A. Date of previous doctor visit. B. Report of a physical examination or assessment of functional capacity. C. Attending physician's report. D. Copies of medical records. A. Date of previous doctor visit. An insurer must obtain a report of a physical exam, the attending physician's report, and copies of medical records. Which of the following statements is true regarding LTC insurance? A. LTC policies must allow a 60-day free-look period. B. Every policy must offer nonforfeiture benefits to the applicant. C. Every policy must offer reduced paid-up insurance to the applicant. D. LTC policies may not include any riders. B. Every policy must offer nonforfeiture benefits to the applicant. Long-term care policies or certificates issued or delivered in this state must offer to the applicant nonforfeiture benefits. Reduced paid-up insurance is one of the possible nonforfeiture options, but it is not necessarily required. LTC policies may contain riders, and must offer a 30-day free-look period. Who must sign the notice regarding replacement? A. Applicant only B. Agent only C. Both the applicant and agent D. Both the agent and the insurer C. Both the applicant and agent Before issuing a replacement policy, the insurer must furnish the applicant with a notice regarding replacement, which must be signed by both the applicant and the agent. Which of the following is NOT an enrollment period for Medicare Part A applicants? A. Automatic enrollment B. Initial enrollment C. Special enrollment D. General enrollment A. Automatic enrollment There are 3 types of enrollment periods for Medicare Part A: initial enrollment period, general enrollment period and special enrollment period.
Which of the following statements is NOT true concerning Medicaid? A. It consists of 3 parts: Part A: hospitalization, Part B: doctor's services, Part C: disability income. B. It is a state program. C. It is funded by state and federal taxes. D. It is intended to provide medical assistance for certain categories of people who are needy. A. It consists of 3 parts: Part A: hospitalization, Part B: doctor's services, Part C: disability income. Medicaid is a state program funded by state and federal taxes that provide medical care for the needy. Parts A-C are part of Medicare. Medicare Part A services do NOT include which of the following? A. Outpatient Hospital Treatment B. Post hospital Skilled Nursing Facility Care C. Hospitalization D. Hospice Care A. Outpatient Hospital Treatment Outpatient treatment is covered under Part B. All of the following statements concerning Medicaid are correct EXCEPT A. Individual states design and administer the Medicaid program under broad guidelines established by the federal government. B. Individuals claiming benefits must prove they do not have the ability or means to pay for their own medical care. C. Persons, at least 65 years of age, who are blind or disabled and financially unable to pay, may qualify for Medicaid Nursing Home Benefits. D. Medicaid is a state funded program that provides health care to persons over age 65, only. D. Medicaid is a state funded program that provides health care to persons over age 65, only. Medicaid is a government funded (both state and federal) program designed to provide health care to poor people of all ages. What is necessary in order to be eligible to receive benefits from a long-term care policy? A. The insured must meet certain economic standards. B. The insured must have been receiving disability benefits for 6 months. C. Age is the only requirement; upon reaching age 65, LTC benefits are available. D. The insured must be unable to perform some activities of daily living. D. The insured must be unable to perform some activities of daily living. Normally to be eligible for benefits from a long-term care policy, the insured must be unable to perform some of their activities of daily living (ADLs). ADLs include bathing, dressing, toileting, transferring, continence, and eating. The part of Medicare that helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care and hospice care, is known as A. Part B. B. Part C. C. Part D. D. Part A. D. Part A. Medicare Part A pays for these services, subject to copayments and limitations on the number of days of care. What is the amount a physician or supplier bills for a particular service or supply? A. Actual charge B. Assignment C. Coinsurance D. Approved amount A. Actual charge Actual Charge is the amount a physician or supplier bills for a particular service or supply. If an insurance company offers Medicare supplement policies, it must offer which of the following plans? A. A & B B. B-N C. A-D D. A D. A An insurance company must make available to each applicant a policy form offering the basic core benefits (Plan A) if it will offer any Medicare Supplement policies. An insurance company does not have to issue all or any of the plans B through N. A man is still employed at age 65 and is now eligible for Medicare. He wants to know what health insurance coverage he is eligible to receive. Which of the following options are available to him? A. Reapplication for group health B. Medicare only C. Both group health and Medicare D. Continuation of group health only C. Both group health and Medicare If a person is still employed at the age of 65, he or she may choose to either continue group coverage and defer Medicare until retirement, or switch to Medicare. The employer cannot provide incentives for switching to Medicare. In order for an insured under Medicare Part A to receive benefits for care in a skilled nursing facility, which of the following conditions must be met? A. The insured must have first been hospitalized for 3 consecutive days. B. The insured must have a Medicare supplement insurance policy. C. There is no benefit provided under Medicare Part A for skilled nursing care. D. The insured must cover daily copayments. A. The insured must have first been hospitalized for 3 consecutive days. Part A covers the cost of care in a skilled nursing facility as long as the patient was first hospitalized for 3 consecutive days, and the services are medically necessary and only up to amounts deemed. All of the following individuals may qualify for Medicare health insurance benefits EXCEPT A. A person age 45 who has a permanent kidney failure. B. A person under age 65 who is receiving Social Security disability benefits. C. A retired person age 50. D. A healthy person age 65. C. A retired person age 50. Under current federal laws, any of the described persons could qualify for Medicare, except for individuals under age 65 who have no special circumstances. All of the following would fall under the definition of Durable Medical Equipment EXCEPT A. Wheel chairs. B. Hospital bed. C. Hospital blankets. D. Oxygen equipment. C. Hospital blankets. Durable Medical Equipment is medical equipment such as oxygen equipment, wheel chairs, and other medically necessary equipment that a doctor prescribes for use in the home. Which of the following statements is INCORRECT concerning Medicare Part B coverage? A. Part B coverage is provided free of charge when an individual turns age 65. B. Participants under Part B are responsible for an annual deductible. C. Part B will pay 80% of covered expenses, subject to Medicare's standards for reasonable charges. D. It is a voluntary program designed to provide supplementary medical insurance to cover physician services, medical services and supplies not covered under Part A. A. Part B coverage is provided free of charge when an individual turns age 65. Those who desire Part B coverage must enroll and pay a monthly premium. A long-term care insurance shopper's guide must be provided in the format developed by which of the following? A. Office of Insurance Regulation B. Director C. Medical Information Bureau D. NAIC D. NAIC A long-term care insurance shopper's guide must be provided in the format developed by the National Association of Insurance Commissioners (NAIC). The shopper's guide must be presented to the applicant prior to completing the application. When an employee is still employed upon reaching age 65 and eligibility for Medicare, which of the following is the employee's option? A. Enroll in Medicare, while the company must provide additional retirement benefits B. Enroll in Medicare when eligible; otherwise, Medicare benefits will be forfeited. C. Wait until the next birthday to enroll D. Remain on the group health insurance plan and defer eligibility for Medicare until retirement D. Remain on the group health insurance plan and defer eligibility for Medicare until retirement If an employee is still employed upon reaching age 65, federal laws require keeping the employee on the group health insurance rolls and deferring their eligibility for Medicare until retirement. The employee has the right to reject the company's plan and elect Medicare but the company can offer no incentives for switching to Medicare. An individual purchased a Medicare supplement policy in March and decided to replace it 2 months later. His history of coronary artery disease is considered a pre-existing condition. Which of the following is true? A. The pre-existing condition waiting period fulfilled in the old policy will be transferred to the new policy, the new one picking up where the old one left off. B. Coronary artery disease coverage will be permanently excluded from the new policy. C. In replacement, pre-existing conditions must be waived, so sickness relating to coronary artery disease will be covered upon the policy's effective date. D. Because this is a new policy, the pre-existing condition waiting period starts over. A. The pre-existing condition waiting period fulfilled in the old policy will be transferred to the new policy, the new one picking up where the old one left off. When an insured replaces one Medicare supplement policy with another, the pre-existing conditions waiting period does not start over. All types of waiting and elimination periods are carried over, not restarted, since that time was served with the original policy. Which type of care is NOT covered by Medicare? A. Respite B. Hospital C. Long-term care D. Hospice C. Long-term care Hospice care, which includes respite care, and hospital care are included in Medicare Part A. Which of the following statements pertaining to Medicare Part A is correct? A. Each individual covered by Medicare Part A is allowed one 90-day benefit period per year. B. Medicare Part A is automatically provided when an individual qualifies for Social Security benefits at age 65. C. For the first 90 days of hospitalization, Medicare Part A pays 100% of all covered services, except for the initial deductible. D. Individuals with ESRD do not qualify for Part A. B. Medicare Part A is automatically provided when an individual qualifies for Social Security benefits at age 65. Workers who have paid FICA taxes automatically qualify for Medicare Part A at age 65. Part A has been prepaid through the FICA taxes. Workers who qualify for Part A are also eligible for Part B; however, it requires that a monthly premium is withheld from Social Security benefits. All of the following are covered by Part A of Medicare EXCEPT A. Home health services. B. Physician's and surgeon's services. C. In-patient hospital services. D. Post-hospital nursing care. B. Physician's and surgeon's services. Physician's and surgeon's services are covered under Part B. A 70-year-old individual who bought a Part B Medicare policy 2 months ago just began kidney dialysis treatments this week. The individual is now applying for a Medicare supplement policy, which would begin in 8 months. Which of the following could the insurer do to avoid paying for the dialysis? A. Deny the supplement policy B. Charge a higher premium C. Declare a pre-existing condition D. Permanently exclude coverage for dialysis C. Declare a pre-existing condition If an applicant is aged 65 or greater and applies for Medicare supplement coverage while covered under Part B Medicare insurance, an insurer cannot alter the price of coverage based on prior claims experience or health status, provided that the application was made during the first 6 months of Part B coverage. The insurer may, however, exclude benefits during the first 6 months based upon a pre-existing condition for which the policyholder received treatment during the 6 months before it became effective. Regarding the return of premium option for LTC policies, what happens to the premium if the policy lapses? A. The insurer will not return any premiums in the case the policy is allowed to lapse. B. The premium will only be returned if the insured dies. C. The insurer will return all of the premiums paid. D. The insurer will return a percentage of the premiums paid. D. The insurer will return a percentage of the premiums paid. The return of premium optional nonforfeiture type benefit is offered by most insurers writing long term care policies. In the event the insured dies or the policy is lapsed, the insurer will return a certain percentage of the premiums paid. What type of care is Respite care? A. Institutional care B. 24-hour care C. Relief for a major care giver D. Daily medical care, given by medical personnel C. Relief for a major care giver Respite Care is designed to provide relief to the family care giver, and can include a service such as someone coming to the home while the care giver takes a nap or goes out for a while. Adult day care centers also provide this type of relief for the caregiver. An insured's long-term care policy is scheduled to pay a fixed amount of coverage of $120 per day. The long-term care facility only charged a $100 per day. How much will the insurance company pay? A. 20% of the total cost B. $120 a day C. $100 a day D. 80% of the total cost B. $120 a day Most LTC policies will pay the benefit amount in a specific fixed dollar amount per day, regardless of the actual cost of care. Which of the following is NOT covered under Plan A in Medigap insurance? A. The first three pints of blood each year B. The Medicare Part A deductible C. Approved hospital costs for 365 additional days after Medicare benefits end D. The 20% Part B coinsurance amounts for Medicare approved services B. The Medicare Part A deductible Medicare Supplement Plan A provides the core, or basic, benefits established by law. All of the above are part of the basic benefits, except for the Medicare Part A deductible, which is a benefit offered through nine other plans. Which of the following does NOT describe hospice care? A. It provides care to people with life expectancies of 1 to 2 years. B. It provides continuous care. C. It provides care in a home-like setting. D. It provides care to terminally-ill people. A. It provides care to people with life expectancies of 1 to 2 years. Hospice provides short-term, continuous care in a home-like setting to terminally-ill people with life expectancies of 6 months or less. The primary eligibility requirement for Medicaid benefits is based upon A. Whether the claimant is insurable on the private market. B. Age. C. Number of dependents. D. Need. D. Need. Medicaid is a program operated by the state, with some federal funding, to provide medical care for those in need. Which of the following entities must approve all Medicare supplement advertisements? A. Federal Association of Insurers B. Consumer Protection Agency C. Insurance Commissioner or Director D. NAIC C. Insurance Commissioner or Director An insurance company must provide a copy of any Medicare Supplement advertisement intended to be used in this state to the Insurance Director for review or approval. When a person applies for Medicare supplement insurance, whose responsibility is it to confirm that the applicant does not already have accident or sickness insurance in force? A. Insurer B. State government C. Active physician D. Agent A. Insurer Although it is illegal for an applicant to intentionally misrepresent himself in an insurance application, it is the insurer's ultimate responsibility to make sure that the applicant does not already have another accident or sickness policy in force. Which of the following is NOT covered under Part B of a Medicare policy? A. Physician expenses B. Routine dental care C. Home health care D. Lab services B. Routine dental care Medicare Part B covers dental expense resulting from an accident only. Which of the following is NOT an activity of daily living (ADL)? A. Dressing B. Taking a bath C. Sleeping D. Eating C. Sleeping The extent of a disability's severity is measured by one's inability to perform activities of daily living independently. Employer health plans must provide primary coverage for individuals with end-stage renal disease before Medicare becomes primary for how many months? A. 12 months B. 24 months C. 30 months D. 36 months C. 30 months The Omnibus Budget Reconciliation Act of 1990 as amended by the Balanced Budget Act of 1997 requires the employer health plan to provide primary coverage for 30 months for individuals with end-stage renal (kidney) disease before Medicare becomes primary. What is the purpose of the Louisiana life and health insurance Guaranty Association?The purpose of this Association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations.
What is the main purpose of the life and health insurance Guaranty Association?Insurance guaranty associations provide protection to insurance policyholders and beneficiaries of policies issued by an insurance company that has become insolvent and is no longer able to meet its obligations. All states, the District of Columbia, and Puerto Rico have insurance guaranty associations.
What is the purpose of the life and health insurance Guaranty Association quizlet?The purpose of the Insurance Guaranty Association is to protect policyholders when an insurance company becomes insolvent. Benefits paid to claimants and policyholders are subject to limits.
What comprises the life and health insurance Guaranty Association?What is a life and health insurance guaranty association? Life and health insurance guaranty associations were created to protect state residents who are policyholders and beneficiaries of policies issued by a life or health insurance company that has gone out of business.
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What is the purpose of the Louisiana life and Health Insurance Guaranty Association quizlet?
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