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| Section | Objectives |
|---|---|
| Accident and Health Insurance Fundamentals | - Disability Income Insurance
|
| Health Insurance Policy Provisions | - Claims and Benefits
|
| General Insurance Regulation | - Licensing Requirements and Responsibilities
|
| Insurance Basics | - Insurance Contracts
|
| Producer Duties and Ethics | - Sales Practices
|
| Government Health Insurance Programs | - Medicaid and Other Programs
|
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NEW QUESTION # 42
Under federal COBRA continuation rules, an employee who loses group health coverage because of termination of employment or reduction in hours will generally be offered continuation coverage for up to:
Answer: D
Explanation:
COBRA generally gives qualified beneficiaries the right to continue employer-sponsored group health coverage after certain qualifying events. For termination of employment, other than gross misconduct, or a reduction in work hours, the standard maximum continuation period is generally 18 months. Other qualifying events, such as death of the covered employee, divorce, legal separation, or a dependent child's loss of dependent status, may result in a longer maximum continuation period, commonly 36 months.
Continuation coverage is not free coverage. The qualified beneficiary typically pays the full group premium plus a permitted administrative charge. COBRA can preserve the same group coverage and provider access for a limited time, but it may be expensive because the employer is no longer subsidizing premiums.
Enrollment deadlines, election notices, payment rules, and employer-plan size requirements are important.
COBRA should not be confused with conversion coverage or an Affordable Care Act marketplace plan.
Conversion coverage is an individual policy issued after group coverage ends under stated conditions.
Marketplace coverage is a separate individual-market option that may be available following loss of employer- sponsored coverage. Producers should explain options carefully and avoid presenting one continuation route as automatically best for every consumer.
References/topics from the Study Guide: COBRA; Group Health Continuation; Qualifying Events; Conversion Privilege; Employer-Sponsored Health Insurance.
NEW QUESTION # 43
Which of the following characteristics is typical of group insurance?
Answer: A
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 # 44
Group coverage for a handicapped dependent child may be continued if the primary insured submits the required proof to the insurance company within what MAXIMUM period of time after the child reaches the limiting age?
Answer: A
Explanation:
A group health policy that terminates dependent-child coverage at a stated limiting age must continue coverage for an eligible dependent child who remains incapable of self-sustaining employment because of a qualifying disability and who remains dependent on the insured group member for support and maintenance.
To preserve that continuation right, the required proof must be furnished within 31 days after the child reaches the policy's limiting age.
This is a time-sensitive protection. The purpose is to prevent automatic termination of coverage solely because a dependent reaches the normal age limit when the child remains disabled and financially dependent.
After initial proof is provided, the insurer may require continuing proof of incapacity and dependency, but it may not demand that proof more often than permitted by law.
The 31-day rule should be distinguished from notice periods for newborn coverage, conversion rights, premium grace periods, and claim notices. Each insurance provision may use a different time period, so examination questions often test the exact statutory deadline.
Study Guide references/topics: group health dependents; limiting age; continuation of coverage; NRS 689B.
035 .
NEW QUESTION # 45
Which statement best describes Medicare Part B?
Answer: B
Explanation:
Medicare Part B is the medical-insurance portion of Original Medicare. It generally helps cover physician services, outpatient care, diagnostic services, preventive care, durable medical equipment, and other covered medical services. Enrollment is generally voluntary, although it may be automatic for certain people who are already receiving Social Security benefits. Most individuals pay a monthly Part B premium, and higher- income beneficiaries may pay an income-related additional amount.
Part B should not be confused with Medicare Part D, which provides outpatient prescription-drug coverage, or with Medicaid, which is a joint federal-state program for eligible individuals with limited income and resources. Part B also differs from Part A, which is primarily hospital insurance. Delaying Part B enrollment without qualifying employer coverage can result in late-enrollment penalties and gaps in coverage, so producers should avoid casual advice and instead direct consumers to current Medicare enrollment guidance.
When discussing Medicare-related products, producers must accurately identify whether a client has Original Medicare, a Medicare Advantage plan, a Medicare supplement policy, and/or a Part D prescription-drug plan.
These arrangements have different rules, premiums, provider networks, and cost-sharing structures.
References/topics from the Study Guide: Medicare Part B; Original Medicare; Enrollment Periods; Medicare Premiums; Medicare Supplement Products.
NEW QUESTION # 46
Which statement best describes a preferred provider organization (PPO)?
Answer: B
Explanation:
A preferred provider organization, or PPO, contracts with a network of preferred providers who agree to provide services under negotiated payment arrangements. Members generally receive the highest level of benefit and lowest out-of-pocket cost when they use participating providers. Many PPOs also permit use of nonnetwork providers, but the member normally pays more through a higher deductible, higher coinsurance, balance billing exposure, or reduced reimbursement.
A PPO differs from a traditional HMO because it commonly provides more flexibility in choosing providers and may not require a primary-care referral for specialist care. However, the tradeoff may be higher premiums, higher cost sharing, and more complex reimbursement rules. A PPO is still managed care; it may use prior authorization, utilization review, formularies, and network rules.
A producer should explain provider-network access, emergency-care rules, deductible and coinsurance amounts, out-of-network payment limitations, and whether a provider is actually participating at the time of enrollment. The phrase "you can see any doctor" can be misleading if nonnetwork care is covered at a lower level or exposes the insured to significant unpaid charges.
References/topics from the Study Guide: PPO; Managed Care; Provider Networks; In-Network and Out-of- Network Benefits; Cost Sharing.
NEW QUESTION # 47
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