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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Accident and Health — General Knowledge | ~68% | - Insurance Concepts and Underwriting
|
| Topic 2: Nevada Statutes, Rules and Regulations | ~32% | - Nevada Health-Specific Regulations
|
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NEW QUESTION # 51
Under a Gold health insurance plan, an insurer would be expected to pay which percentage of medical costs?
Answer: A
Explanation:
A Gold Marketplace health plan has an actuarial value of approximately 80%. Therefore, the insurer is expected to pay about 80% of covered medical costs for a standard population, while enrollees as a group pay approximately 20% through deductibles, copayments, and coinsurance.
Actuarial value does not mean that the insurer pays exactly 80% of every individual's bills. A particular insured may pay more or less than 20% in a year depending on the services used, the plan's deductible, copayment structure, provider network, prescription-drug costs, and whether the annual out-of-pocket maximum has been reached. It is an overall measure of expected cost sharing for covered benefits.
The standard metal levels are Bronze at 60%, Silver at 70%, Gold at 80%, and Platinum at 90%. Gold plans generally have higher monthly premiums than Bronze or Silver plans but lower cost sharing when health care is received. Platinum plans generally have the highest premiums and the lowest cost sharing.
Study Guide references/topics: Affordable Care Act; Marketplace plans; metal levels; actuarial value; deductibles; copayments; HealthCare.gov plan categories .
NEW QUESTION # 52
Which of the following persons is NOT required to be licensed by the Nevada Insurance Commissioner?
Answer: A
Explanation:
A salaried insurance company employee performing only clerical and administrative work is not required to hold an insurance producer license. The exemption applies when the employee does not sell, solicit, or negotiate insurance and is not compensated by commission based on insurance transactions.
Licensing is required for persons whose activities bring them into the regulated functions of insurance production, brokering, adjusting, or other licensed insurance activity. A person who procures insurance for an insured is acting in a producer or broker capacity and requires appropriate authority. An individual involved in investigating and settling claims may require an adjuster license depending on the duties performed.
Likewise, an agency clerk who receives commissions related to processed applications is no longer functioning solely as a clerical employee; commission-based activity indicates involvement in the insurance transaction.
The distinction is based on the actual work performed, not merely the person's job title. A company may call someone an assistant, representative, clerk, or customer-service employee, but the individual must be licensed if the person sells, solicits, negotiates, or otherwise performs regulated insurance functions.
Study Guide references/topics: producer licensing; licensing exemptions; clerical employees; sales, solicitation, and negotiation; NRS 683A.117 .
NEW QUESTION # 53
A group health policy that covers hospital expenses MUST also cover:
Answer: C
Explanation:
A group health policy that provides hospital-expense coverage must also provide coverage for routine physical examinations. Routine examinations are preventive services intended to identify health concerns early, promote wellness, and reduce the risk that a medical condition will progress before treatment begins.
Burial expenses are not health-insurance benefits. They are ordinarily addressed through life insurance, final- expense coverage, or other arrangements. Elective cosmetic surgery is generally excluded unless it is medically necessary, reconstructive, or otherwise required by the policy or applicable law. Travel expenses for caretakers are likewise not a standard mandatory group health benefit.
The key point is that group health coverage is not confined to hospitalization after illness or injury occurs.
Required provisions can include preventive and health-maintenance benefits. Routine physical examinations allow the insured to receive medical assessment before a condition requires hospital confinement or major treatment.
The exact scope of a routine examination, frequency limitations, network requirements, and whether additional diagnostic services are covered may depend on the policy and applicable preventive-care rules. But among the choices, routine physical examinations are the mandated benefit associated with hospital-expense group coverage.
Study Guide references/topics: group health required provisions; hospital expense coverage; preventive care; routine physical examinations; Nevada group-health policy requirements .
NEW QUESTION # 54
Which of the following characteristics is typical of group insurance?
Answer: D
Explanation:
Choice C is correct. Group insurance is designed to cover members of an eligible class, commonly all full- time employees of an employer, subject to the plan's participation, waiting-period, and eligibility rules. The employer or policyholder receives the master contract, while individual employees receive certificates of coverage describing their benefits. Therefore, choice B is incorrect because employees ordinarily do not receive separate individual policies. Medical examinations are generally not required for eligible employees during an initial enrollment period, especially when coverage is guaranteed issue. Choice A is therefore not a typical group-insurance feature. Enrollment is also not automatically available at any time. Employees normally enroll when first eligible or during an open enrollment period; late entrants may face evidence-of- insurability requirements or other conditions. Group insurance spreads risk across a defined group and is typically less individually underwritten than individual insurance. The key requirement is that the group be formed for a purpose other than obtaining insurance and that coverage be offered according to objective eligibility standards. Study Guide References/Topics: Group Health Insurance; Group Eligibility; Master Contract and Certificate of Coverage.
NEW QUESTION # 55
Under a typical coordination-of-benefits rule, a child is covered under both parents' group health plans.
Which plan is generally primary when the parents are married and neither plan contains an exception?
Answer: C
Explanation:
Coordination of benefits, or COB, establishes the order in which multiple health plans pay when an insured is covered by more than one plan. For a dependent child covered by both married parents' group health plans, the common "birthday rule" generally makes primary the plan of the parent whose birthday occurs earlier in the calendar year. The rule compares the month and day of birth, not the year. If both birthdays are the same, the plan that has covered the parent longer is generally primary.
The primary plan pays first according to its own policy terms. The secondary plan then considers the remaining eligible expense and may pay an additional amount, subject to its coordination-of-benefits provision. COB is intended to prevent duplicate recovery exceeding the actual covered expense while still allowing the insured to receive the benefit of multiple coverages.
Special rules can apply in divorce, custody, court-order, active-versus-retired employee, Medicare, and other situations. The producer should never assume that one generic rule governs every family arrangement. Plan documents and applicable law control. For examination purposes, the birthday rule is the standard answer when the parents are married and no special circumstance is stated.
References/topics from the Study Guide: Coordination of Benefits; Primary and Secondary Coverage; Birthday Rule; Group Health Insurance; Dependent Coverage.
NEW QUESTION # 56
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