Health Law 1

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Health Law 1 1. Billy Bob is covered under his employer's group health insurance plan. His family is also covered. Billy Bob's 16 daughter becomes pregnant. The baby is born premature and the Bob family is at a loss as to how they will pay these medical costs. Which statement by the agent would be the most correct? "There is no coverage for 18 months" "the insurance company will pay the bills, for 18 months" "the baby is covered for 18 months" "wasn't me" 2. Creditable coverage, as defined under the Health Insurance Portability & Accountability Act, includes: I. Group Health Plans II. Individual Health Plans III. Florida Comprehensive Health Association IV. Medicare & Medicaid I I & II I, II, III All the above 3. Which of the following are elgible for medicare benefits? 1. folks aged 65 and over 2. folks under age 65 receiving social security disability benefits 3. folks with chronic liver problems 4. folks with chronic kidney problems 1, 2, & 3 1, 2, & 4 1, 3, & 4 all the above 4. Which of the following statements concerning a non-cancellable policy is/are true? 1. the premiums can not be raised except by class 2. the premiums can not be raised 3. the benefits may changed only by class 4. the benefits can not be changed 1 & 3 2 & 3 1 & 4 2 & 4 5. An HMO contract must list all of the following except: All services and limitations covered Outline of pre-existing conditions for covered members and their children a grace period of not less than ten days Provisions pertaining to Medicare enrollment and disenrollment 6. Which of the following would not be considered a small employer under the Health Care & Insurance Reform Act of 1993? a sole proprietor an independent contractor a self-employed individual none of the above 7. Chiropractic Treatment must be included in a health policy by Florida Law? True False 8. Extensions of Benefit is a term used in the health insurance industry which relates to claims that occurred while a policy was in force and then later the policy is no longer in effect but the insured is still disabled. If an HMO terminates coverage, how long will the HMO be responsible for the insured's disability? 1. Until 12 months have expired or another carrier assumes coverage, whichever is earliest 2. Until 12 months have expired or another carrier assumes coverage, whichever is latest 3. Will pay for life as long as the insured was covered while the policy was in force 4. Coverage terminates when the policy is terminated 1 2 3 4 9. Which of the following statments concerning the Florida Employee Health Care Access Act are true? 1. Mandates guarantee issue for small groups 2. Determined open enrollments for all small groups 3. Mandated a modified community rating methodology 4. Allowed for genetic information underwriting 1 & 2 1 & 3 1, 2, & 3 All the above 10. Benjamin is totally disabled under his own occupational disability policy. He has been receiving monthly payments for two years. How often must Benjamin submit proof of loss? every six months every year every 18 months every two years 11. John's individual health insurance policy was reinstated effective November 15. He was injured in an accident the following day. Choose the correct statement pertaining to this situation. there would be no coverage for ten days after reinstatement John would be covered as accidents are covered immediately after reinstatement there would be no coverage until the probationary period has expired John would be covered as there is no new waiting period for sickness or accidents following reinstatement 12. Larry was a brick layer who had puchased a $5000 per month disability policy back in brick-laying school. He was issued a standard policy which he had been paying premiums for five years. In the evenings he finished medical school and has since been practicing medicine as a surgeon. Having sliced off his hand with a scaple he submits a claim. Which course of action would the company most likely follow? the company would pay the $5000 the company would pay a higher benefit to reflect what the premium would have purchased at a surgeon's occupational classification the company would pay the $5000 and refund any premium the company would deny the claim 13. Which statement concerning the newborn child coverage of a family member in an HMO contract is correct? The child is covered after 14 days for a period of 12 months. The child is covered after 14 days for a period of 18 months. The child is covered immediately for a period of 12 months. The child is covered immediately for a period of 18 months. 14. All of the following are examples of typical pre-exisiting conditions except: An adopted child,with renal failure, of a covered individual An individual who cancelled his individual health insurance policy within the last 18 months An individual with sickle cell anemia 15. Newborn hearing screening is a required coverage in Florida? True False 16. Which of the following is not a part of the "special procedures" when dealing with individuals eligible for Medicare? Subscribers must be told when they enroll in an HMO they are disenrolled from Medicare The agent is required to ask if the person solicited is covered by another health insurance policy and have forms attesting to this fact The agent must inform the prospect that re-enrollment in Medicare is subject to a 90 day waiting period The notice of buyer is on the first page of application 17. A "fictitious" group involves organizing any of the following to buy group insurance 1. A group of neighbors 2. Several independent Realtors 3. An association of electrical contractors 1 only 2 only 3 only 1 and 2 18. When must an HMO contract be delivered? Ten days 30 days 31 days 45 days 19. The minimum grace period in a health insurance policy paid on a quarterly basis is: 7 days 10 days 30 days 31 days 20. Lisa was covered under an individual health insurance policy for the last five years which lapsed February 28. Six weeks later she felt dizzy and her vision blurred. Thinking better of her situation she immediately purchased an individual health insurance policy. On April 15th, she was diagnosed with a brain tumor. Which statement reflects poor Lisa's plight? she is fully covered no coverage, pre-exisiting condition 21. The Health Insurance Portability & Accountability Act (HIPAA) requires any person with 18 months of creditable coverage, who does not have access to other health insurance, be given health insurance regardless of their health. True False 22. When does maternity coverage become effective for a group with two or more employees? 3 months 6 months 9 months immediately 23. An International Health policy: 1. Is sold at the airport 2. Are not subject to rate or form regulations by the Dept. of Insurance 3. Covers only residents of a foreign country 4. Issued on an annual basis 1 & 2 2 & 3 none of the above All the above 24. Juilie's group health insurance became effective March 1. She found out March 7 that she was three months pregnant. Which of the following statements are true? The pregancy is covered because there is no pre-existing condition for maternity There would be no coverage as maternity is excluded as a preexisting condition. 25. Which of the following statements concerning the coordination of benefits provisions is/are true? 1. it is a cost containment measure 2. it is required among group policies 3. it prevents benefits from exceeding 100% of expenses incurred 4. does not apply to medicare supplement policies 1 & 2 1 & 3 1, 2 , & 3 all the above 26. Which of the following statements concerning group health insurance is/are correct? 1. may not engage in individual underwriting 2. insureds are given a certificate of coverage 1 only 2 only 1 & 2 none of the above 27. Which of the following statements is not true regarding the Florida Comprehensive Health Association? no new enrollments as of 1991 guaranteed heath coverage to all, provided they could not obtain coverage elsewhere any organization selling health insurance in Florida must belong, sharing in the losses and the gains rates charged are up to 250% of standard rates 28. George's Glue Factory has 25 employees covered under their group health insurance policy. Which of the following statements concerning alcoholism and drug addiction coverage is true? there are no requirements in Florida law regarding drug and alcohol coverage it must be offered to all employees it must be offered to the employer, who may turn it down mandatory coverage for groups of 25 or more 29. An individual has how many days in which to notify the company of a claim? 15 days 20 days 30 days one month but not less than 30 days 30. Which of the following is not covered under Medicare Part "A"? post hospital skilled nursing care hospice care post hospital home services ambulance services 31. Melli Noma, a subscriber in an HMO, discovers an unusually colored mole on her shoulder. Knowing skin cancer runs in her family, she should do which of the following? Contact her HMO for a referral to her dermatologist Contact an open or closed panel dermatologist 32. Sam's father had sickle-cell anemia. As well as his uncle. Sam otherwise represents a very favorable risk to the insurance company. Which course of action would the insurance company most likely pursue? The insurance company would deny Sam coverage because of his propensity to sickle-cell anemia the insurance company would charge him a higher premium the insurance company would reduce the benefits applied for they would issue the policy as applied for 33. Faye is hospitalized for a serious illness. After being dismissed she submits a claim to: 1. the agent 2. the company 1 only 2 only either 34. A group with 7 employees may exclude pre-existing conditions for: 3 months 1 year 6 months 2 years 35. The Legal Action provision states that a policyowner must wait a minimum of how many days after submitting Proof of Loss to an Insurance company before a lawsuit against the company? 30 60 45 90 36. What must the insured do if the insurance company does not send a claim form with-in the appropriate time frame? the insured is not required to do anything, the insurance company will automatically be liable for the loss bring suit with-in a 90 day period present proof of the loss in any written manner showing the nature of the loss, extent of loss and other information the insurance company has 45 days in which to furnish proof-of-loss forms to the claimant, otherwise the company is automatically liable for the loss 37. The Florida Health Insurance Coverage Continuation Act (HICCA) Applies to companies with 20 or more employees Coverage may be extended for 24 months Allows companies to charge 115% of the regular group rate Big Dawg is trying to fool us, no such thing 38. Which of the following statements concerning Medicare is/are true? 1. part "a" is optional 2. a premium is deducted for parts "a" & "b" 3. part "a" has an annual deductible 4. part "b" is optional 1, 2, & 3 2, 3, & 4 1, 2, & 4 4 only 39. Which of the following cannot write health insurance in Florida? Career Agent Health Insurance Broker Captive Agent General Agent 40. A medicare supplement has _______ free look. 10 days 20 days 30 days 45 days 41. All of the following statements concerning the Florida Health Insurance Coverage Continuation Act are true except: Designed for groups of 50 of less Provides for extended coverage for up to 18 months Restricts the premium to 115% of the groups rate May be extended for 29 months in some cases 42. Which of the following are losses not covered in a typical health insurance policy? 1. mental disorders 2. cosmetic surgery 3. private aviation 4. act of war 1, 2, 3, & 4 1, 2, & 3 1, 2, & 4 2, 3, & 4 43. What type of contract pays a stated amount in the event of loss? reimbursement stated loss of value valued 44. All of the following are permitted to sell HMOs in the state of Florida except: 1. A licensed health only agent 2. An unlicensed officer of an HMO 3. A licensed life agent 2 only 2 and 3 3 only all the above 45. The amount paid by the HMO to the provider in exchange for services is called: Pre-payment arrangement Capitation Arrangement Provider agreement Co-payment Arrangement 46. A small group is defined as: 3-50 1-10 less than 10 50 or less 47. Which of the following is not considered an unfair claim settlement practice pertaining to HMO's? a material misrepresentation to an insured failing to affirm or deny coverage upon written request within a reasonable time, not to exceed 15 days providing un-reasonable explanation for non-payment altering an application with insured's knowledge 48. Which of the following statements concerning HMO "open enrollments" is not true? Open enrollment must be offered every year Open enrollment period lasts no less than 30 days During open enrollment, eligible members may enroll regardless of health condition Open enrollment must be offered every 18 months 49. Which of the following may generally be excluded under a major medical policy? bones & joints of the jaw treatment for diabetes osteoporosis none of the above

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