Hospitalization Insurance and Health Maintenance Organizations, Exams of Nursing

Download Hospitalization Insurance and Health Maintenance Organizations and more Exams Nursing in PDF only on Docsity! P ag e1 TEXAS LIFE HEALTH INSURANCE Actual Exam 2024-2025 Latest Version With 100 + Questions and Correct Answers All of the following are methods of determining the extra rate for a substandard class or risk EXCEPT a.) variable additional premium b.) tabular rating c.) rated-up age d.) flat additional premium - ANSWER>> A Medical expense insurance is commonly referred to as - ANSWER>> Hospitalization insurance A form of group insurance that may include students, campers, passengers of a common carrier, volunteer groups, and sports teams is known as - ANSWER>> Blanket insurance In a limited policy, to ensure that the insured has sufficient notice that the coverage is limited, every policy that provides limited coverage must, by law, state plainly on the first page of the policy, - ANSWER>> "THIS IS A LIMITED POLICY" Which of the following cares for patients who do not require acute hospital nursing care but who need impatient supervision by a registered nurse? a.) managed care P ag e2 b.) skilled nursing facilities c.) home health care d.) urgent care - ANSWER>> B Which of the following allows an employer to combine a high- deductible health plan with a spending or reimbursement account? a.) health reimbursement accounts (HRA) b.) multiple employer trusts (MET) c.) health savings account (HSA) d.) consumer-driven health plans (CDHP) - ANSWER>> D An arrangement that allows very small groups to have some of the benefits of group insurance, especially at a lower cost, is called - ANSWER>> Franchise insurance All of the following statements about franchise insurance are true EXCEPT a.) there is a master policy b.) plans may be contributory c.) one premium is paid for the entire group d.) plans may be noncontributory - ANSWER>> A Social security pays all of the following except a.) workers comp b.) retirement benefits to workers P ag e5 In addition to premium, the consideration for a policy includes - ANSWER>> the statements made in the application Penny hasn't paid her annual premium of $400, but her policy is still in the grace period. She has an accident and files a claim to be reimbursed for $1,500 in medical expenses. She will receive - ANSWER>> $1,100 Darryl is a salesman. Last year was a bad year for him, and he earned only $1,000 a month. This year he was back on track and earned $3,000 a month. He has just become disabled. Under the average earnings clause, his monthly benefit will be - ANSWER>> $3,000 All of the following are required health insurance provisions EXCEPT a.) grace period b.) cancellation c.) proof of loss d.) time of payment of claims - ANSWER>> B It has been 1 day short of a year since Jerry provided his insurer with proof of loss. He decides he's not satisfied with the settlement offer he has received. How much longer does he have to file a suit against the insurer? - ANSWER>> 1 day and 2 years P ag e6 Sharon is anxious to know if her claim has been accepted. She hasn't heard back from the insurer for 29 days since she filed her claim. How much longer must she wait before suing the insurer becomes an option? - ANSWER>> 31 days Javier applies for policy reinstatement on June 1. If he doesn't hear back from the company, on what date can he assume his reinstatement application has been accepted? - ANSWER>> July 15 A shorter grace period results from - ANSWER>> A more frequent premium mode Gita paid an annual premium of $200 and 6 months later, her policy was cancelled and she received a pro rata refund. The amount Gita received is - ANSWER>> $100 Su has a loss on January 1. By what date must proof of loss be filed for a claim? - ANSWER>> March 31 Which of the following is NOT part of the contract, according to the entire contract provision? a.) policy document b.) statements made by agent c.) endorsements d.) attachments - ANSWER>> B P ag e7 Faed buys a health insurance policy in 2015. If he lives in a typical state, in what year will it become incontestable? - ANSWER>> 2017 The insured will receive an insurer approved copy of any change in the policy as notification of the policy change. This copy must be - ANSWER>> Attached to the policy, making it part of the entire contract Which of the following may be used by the insurer to deny a claim after two years from the date of issue of the policy? a.) any response on application questionnaire that is incorrect or misleading regarding health of the insured b.) misstatements by the insured on application questionnaire c.) fraudulent misstatements d.) material misstatements made by the insured on application - ANSWER>> C Joe has a claim under his health policy three months after the policy was issued. Which of the following statements is CORRECT? a.) company may void the contract or deny claim for fraudulent misstatements only b.) company may void contract or deny claim for any misstatement on application c.) company does not have to prove fraudulent misstatement P ag e1 0 Normally, written proofs of loss must be furnished within how many days after the loss? - ANSWER>> 90 When Betty purchased her insurance policy, her age was recorded as 32 when she was actually 34. Assuming her policy includes the misstatement of age provision and the insurance company discovers this 4 years later, Betty's policy - ANSWER>> limits will be lowered If a policy includes the provision on conformity with state statutes, and the state changes the law to be in conflict with another provision of the policy - ANSWER>> the provision will automatically be amended to conform to the minimum requirement of the statutes Mike allows his policy to lapse, then applies for reinstatement using the company's required application. The company does not inform Mike either that the policy has been accepted or that the policy is being rejected. At what point can Mike consider the policy reinstated? - ANSWER>> After 45 days Because the insurer needs time to respond to a claim, the law provides the insurer a window during which the insured cannot sue to recover under a claim. This window lasts for - ANSWER>> 60 days A revocable beneficiary - ANSWER>> may be changed without the beneficiary's consent P ag e1 1 Joe took out a disability policy while working as a very successful stockbroker. A few years later, he decides to take a less stressful job at a not-for-profit organization, writing about financial issues. He loves his new job and doesn't mind the fact that he makes a lot less money. When he becomes disabled 3 years later, his disability benefit is more than he has made in salary in 3 years. If the policy contains an average earnings clause, Joe's benefit will A) be the greater of Joe's monthly earnings at the time the disability started, or the average monthly earnings for the period of 2 years immediately preceding his disability B) be the same as listed in the policy C) be the greater of Joe's monthly earnings at the time the disability started, or the average monthly earnings for the period of 2 years immediately preceding his disability. In addition, the insurer will return some of the excess premiums that paid - ANSWER>> C Carmen gets her health insurance policy on May 1, and on May 3 she decides she doesn't want it and returns it to the company. On May 6, she is hit by a car. The company A) will pay any resulting claim minus the amount of the returned premium B) will pay any resulting claim only if the premium has not yet been returned to Carmen C) will pay any resulting claim because she was injured within the 10-day free-look period P ag e1 2 D) will only return any premium Carmen has paid and not any resulting claim - ANSWER>> D) will only return any premium Carmen has paid and not any resulting claim Jennifer takes out an optionally renewable health policy with an annual premium due on June 14. The insurer decides it no longer wants to insure people with first names longer than five letters. The insurer may - ANSWER>> cancel the policy, but only on June 14 of the next year To receive benefits from a disability income policy due to sickness, the insured must be - ANSWER>> Totally disabled Which disability income rider is designed to fill gaps of coverage under workers comp or state disability benefits are denied? - ANSWER>> Social insurance supplement rider The benefit that protects against the erosion of purchasing power for fixed disability benefits is known as - ANSWER>> Cost of living benefit The benefit that pays the regular total disability benefit during the elimination period when the insured is hospitalized is known as - ANSWER>> Hospital confinement rider The option that allows an insured to purchase additional amounts of disability income protection is known as - ANSWER>> future increase option P ag e1 5 Lauren's policy covers hospital expenses by paying a specified, predetermined amount per day, as shown in a schedule in the policy. Laurens policy pays on - ANSWER>> An indemnity basis Carmen falls and breaks her leg, incurring $2,000 in medical expenses. Her policy pays the entire amount. Carmen has a A) policy with first dollar coverage B) surgical expense policy C) hospital expense policy D) medical expense policy - ANSWER>> A) policy with first dollar coverage A policy with first dollar coverage begins to pay when medical expenses are incurred, without a deductible. Maternity benefits must be provided on the same basis as nonmaternity benefits - ANSWER>> if the policy covers an employee group of 15 or more people No loss/ no gain laws require - ANSWER>> Replacing health insurance policies to cover any conditions for which there are ongoing claims under existing coverage. Which of the following would most likely be covered under a medical expense policy? a.) Carmelita decides to get a flu shot this year b.) Gary goes to the doctor each year for an annual check-up P ag e1 6 c.) Earl requires some help getting dressed in the morning d.) Gertrude steps on a rusty nail and requires a tetanus shot - ANSWER>> D All of the following statements about comprehensive dental policies are true EXCEPT a.) with a comprehensive dental plan, there is a specified dollar amount paid per year b.) comprehensive dental plans provide routine dental care services without deductibles or coinsurance c.) with a comprehensive dental plan, there is a specified dollar amount paid per family member covered d.) comprehensive dental plans provide routine dental care services after the insured pays deductibles - ANSWER>> D All of the following statements regarding dread disease policies are true EXCEPT a.) polices are often expensive in comparison to full health cover due to the expense of the disease to treat b.) policies are often inexpensive in comparison to full health coverage due to the low frequency of the disease covered c.) dread disease policies can cover heart disease or cancer d.) a dread disease policy is a limited policy, covering only a limited, specified risk - ANSWER>> A Hospital income insurance is also known as - ANSWER>> Indemnity insurance P ag e1 7 All of the following statements about hospital income insurance are correct EXCEPT a.) the payout begins when the insured is confined to the hospital and ends on final day of hospitalization b.) policy pays indemnity directly to the insured c.) policy provides a flow of income to the insured d.) policy is intended to cover expenses for hospitalization - ANSWER>> D All of the following statements about prepaid dental plans are correct EXCEPT a.) services are offered based on fixed per-membership-per- month payments b.) prepaid dental plan must provide that any licensed dentist may participate as a provider c.) prepaid dental plans operate much like health maintenance orgs d.) only a select few licensed dentist may participate as providers - ANSWER>> D Copies of complaints and responses of any dentist in a prepaid dental plan must be kept for a period of - ANSWER>> Three years Scheduled benefits are generally - ANSWER>> lower than reasonable and customary allowances P ag e2 0 charges, whereas prepaid dental plans pay on a capitation basis. A prepaid dental plan that wants to restrict an enrollee's ability to receive services from a class of providers - ANSWER>> Must describe the limitations in the evidence of coverage and in all solicitation documents Hospital indemnity insurance pays - ANSWER>> an income for each day the insured is confined to the hospital Vision care insurance is generally needed to cover all of the following EXCEPT A)eye examinations B)costs of contact lenses C)costs of prescription lenses D)injury to the eye - ANSWER>> D. Injury to the eye Credit health insurance covers - ANSWER>> debtor For nonroutine treatments, a comprehensive policy generally pays - ANSWER>> a percentage of the reasonable and customary charges after a deductible P ag e2 1 An employer that has fewer than 20 employees - ANSWER>> Is not subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA) Richard encourages his father to move home. His father agrees, but insists on paying rent and something towards utilities and food. His father is 62 years old and continues to file a tax return. Which of the following is most likely? a.) Richard's father is covered by Medicare since he is collecting social security retirement benefits b.) Richard's father is not a dependent and thus not eligible for coverage under Richard's group health insurance plan - ANSWER>> B When working couples are both covered under each one's group health insurance plan, which statement is NOT correct regarding coverage for dependent children? a.) birth day and month of parents are often used to determine which plan is primary b.) if parents are separated or divorced, plan for the parent with custody is primary, barring any legal arrangements c.) plan of parent that has first birthday of year is primary d.) the fathers policy will always pay first, or be primary coverage - ANSWER>> D When an individual is insured under two group health insurance plans, such as when both husband and wife are each P ag e2 2 covered under each ones group health insurance - ANSWER>> Each one's own employers policy would as if there is no other policy In general, premiums for group insurance are based upon which type of rating? - ANSWER>> Experience rating The Americans with disabilities act is applicable to employers with how many employees? - ANSWER>> 15 or more The age discrimination in employment act applies to employers with how many employees and is directed to employees of what age? - ANSWER>> 20 or more employees and age 40 or older Which of the following legislation amended the social security act to make Medicare insurance secondary to group health insurance plans when a person is covered by both? a.) Consolidated Omnibus Budget Reconciliation b.) Tax Equity and Fiscal Responsibility Act (TEFRA) c.) Employee Retirement and Income Security Act (ERISA) d.) Health Insurance Portability and Accountability Act (HIPPA) - ANSWER>> B Under the coordination of benefits rule, the primary company pays - ANSWER>> as if there were no other coverage P ag e2 5 Under Medicare part B, individuals pay a deductible each - ANSWER>> year After the deductible is satisfied, part B pays what percentage of all approved charges? - ANSWER>> 80% Doctors and suppliers who agree to accept the amount Medicare will pay are said to have agreed to A) assessment B) payment C) capitation D) assignment - ANSWER>> D. Assignment Some kind of supplement to Medicare is needed by almost everyone covered by Medicare. Which of the following individuals would NOT need Medicare supplement insurance? A) Carl, whose net worth is high enough to cover any medical bills that might incur B) Ken, whose income is low enough to qualify him for help from Medicaid P ag e2 6 C) George, whose medical conditions are currently under control - ANSWER>> B Medicare SELECT policies offer ______________________ coverage, compared with standard Medigap policies. - ANSWER>> same All of the following statements about Medigap insurance are correct EXCEPT a.) Medigap policies are available through Medicare b.) Medigap plan A covers basic benefits c.) Medigap policies were standardized by the NAIC d.) Medigap policies are sold by private insurance companies - ANSWER>> A Which of the following benefits are NOT required in any Medicare supplement policy? a.) part B co-payments on Medicare-approved charges for physicians& medical services b.) skilled nursing care benefit that covers part A co-payments for the 21st through 100th day of skilled nursing facility care c.) all charges for 365 days of hospitalization after all part A inpatient hospital& lifetime reserve days are used up d.) part A co-payments for 61st through 90th day of hospitalization - ANSWER>> B P ag e2 7 Under social security disability benefits, disabled workers receive a benefit equal to - ANSWER>> Their primary insurance amount For each benefit period, Medicare will pay the full cost of up to how many days of hospital care? - ANSWER>> 60 Medicare will pay the entire cost for skilled nursing facility care for the first - ANSWER>> 20 days Individuals who are eligible for social security benefits become eligible for Medicare part A benefits as of - ANSWER>> the first day of the month in which they turn 65 Most long-term care policies issued recently - ANSWER>> Guarantee renewability The benefit for home health care provided under the long term-care policy usually is - ANSWER>> 60% of the regular nursing home benefit Nursing home care is generally covered by - ANSWER>> long- term care policies Which of the following would be least likely to be a good candidate for an LTC policy? P ag e3 0 All of the following benefits are provided under part A of Medicare EXCEPT a.) hospice care b.) physicians services for inpatient care c.) skilled nursing facility care d.) inpatient hospital care - ANSWER>> B In group insurance, the evidence of a contract between insurer and the employer or association is - ANSWER>> The policy The policy itself is the evidence that a contract exists, whether it is an individual, association or group policy. In group insurance the policy is referred to as the master policy. Individual insureds do not receive a copy of the policy, since there is no agreement between the insureds and the insurer. In a disability income policy, there is a period during which no benefits are I'll be paid for illness of any kind. This period usually does not apply to accidents, only to illness. This interim is called - ANSWER>> The probationary period Which of the following is NOT eligible for Medicare coverage? a.) people age 65 and older who are not eligible for social security but who are willing to pay a monthly premium b.) people with any life-threatening condition c.) people age 65 and older who are eligible for social security P ag e3 1 d.) people of any age who have been entitled to disability benefits for 24 months - ANSWER>> B Which of the following phrases correctly describes Medicaid? a.) is usually totally funded by the states with little or no federal reimbursement b.) provides medical benefits for certain low-income people, for the disabled, and for families with dependent children c.) supplements Medicare before age 65 d.) all of these - ANSWER>> B