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| Section | Weight | Objectives |
|---|---|---|
| Insurance Regulation and General Principles | 20% | - New York Insurance Code and Laws
|
| Accident and Health Insurance | 35% | - Government Health Programs
|
| Underwriting, Marketing and Sales Practices | 15% | - Application and Underwriting Procedures
|
| Life Insurance Products and Provisions | 30% | - Policy Provisions, Riders and Options
|
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NEW QUESTION # 121
Which of the following is an example of risk sharing?
Answer: C
Explanation:
Risk sharing is a risk management technique in which a group combines resources so that losses experienced by a few are spread across many. The classic insurance concept behind this is pooling : each participant contributes money to a common fund, and the fund is used to pay covered losses as they occur. Option B describes this directly- pooling money to cover malpractice exposures -because malpractice losses can be unpredictable and potentially severe, and sharing them across a group reduces the financial impact on any one member.
The other options describe different risk management methods. Option A (not purchasing a car) is risk avoidance -eliminating the exposure entirely. Option C (installing sprinklers) is risk reduction/loss control , lowering the frequency or severity of loss. Option D (purchasing an insurance policy) is primarily risk transfer
, shifting the financial consequences of specified losses to an insurer in exchange for a premium. Because only option B reflects spreading losses among a group through pooling, it is the best example of risk sharing .
NEW QUESTION # 122
Under Workers ' Compensation, injured employees are covered for all of the following losses EXCEPT
Answer: C
Explanation:
Workers' Compensation is a form of insurance that provides benefits to employees who suffer work-related injuries or occupational illnesses . It is designed as a no-fault system , meaning employees receive benefits regardless of who caused the accident, while employers are generally protected from lawsuits related to workplace injuries. Workers' Compensation typically provides several types of benefits, including payment of necessary medical expenses , replacement of a portion of lost wages , and coverage for occupational illnesses or diseases that arise from employment conditions. In cases of severe injury or death, additional disability or survivor benefits may also be provided.
However, Workers' Compensation does not provide benefits for pain and suffering . Compensation for emotional distress or general suffering is usually associated with civil liability lawsuits, not with Workers' Compensation benefits. The system focuses primarily on economic losses -such as medical costs and lost income-rather than non-economic damages. Because of this trade-off, employees receive quicker access to benefits without needing to prove employer negligence, but they also give up the right to sue the employer for additional damages like pain and suffering.
NEW QUESTION # 123
Under the Affordable Care Act, insurers MUST offer plans within health insurance exchanges that meet distinct levels of coverage. What metal tier is REQUIRED to have an actuarial value of 70% with covered individuals paying 30% through deductibles, co-pays, and other cost sharing features?
Answer: A
Explanation:
Under the Affordable Care Act (ACA), qualified health plans offered on the individual and small-group exchanges are categorized into metal tiers based on actuarial value (AV) -the percentage of expected average medical costs the plan is designed to pay for a standard population. The ACA's standard tiers are Bronze (60% AV) , Silver (70% AV) , Gold (80% AV) , and Platinum (90% AV) . A plan with a 70% actuarial value is therefore a Silver Plan , meaning that, on average, the insurer pays about 70% of covered healthcare expenses and covered individuals pay about 30% through deductibles, copayments, coinsurance, and other cost-sharing (not including premiums).
This question's wording matches the defining feature of the Silver tier: 70/30 cost-sharing on average . Gold and Platinum tiers have higher actuarial values (so lower expected cost sharing), while Bronze has a lower actuarial value (higher expected cost sharing). Therefore, the required tier at 70% AV is the Silver Plan .
NEW QUESTION # 124
Medicaid provides which coverage that Medicare does NOT?
Answer: C
Explanation:
The correct answer is custodial care . Medicaid is a government health assistance program for individuals who meet certain income and resource requirements , and one of its important features is that it may provide coverage for long-term custodial care , particularly in a nursing home or similar setting for eligible individuals. Custodial care generally refers to assistance with activities of daily living , such as bathing, dressing, eating, and moving about, rather than treatment intended to cure or improve a medical condition.
Medicare, by contrast, is primarily designed to cover acute care and medically necessary services. It does cover services such as ambulance transportation , inpatient hospital services , and certain forms of inpatient psychiatric care , subject to policy limits and eligibility requirements. However, Medicare generally does not pay for ongoing custodial care when that is the only type of care needed.
This distinction is commonly tested in accident and health insurance licensing exams because it highlights the difference between medical insurance for acute or skilled care and public assistance coverage for long-term support needs . Therefore, the service Medicaid provides that Medicare does not is custodial care .
NEW QUESTION # 125
With respect to small group health benefit plans, a carrier may discontinue coverage or may refuse to renew such a plan if the employer
Answer: B
Explanation:
Under New York small group health benefit plan rules, carriers generally must renew coverage for an employer group, but there are specific exceptions where a carrier is permitted to discontinue or refuse renewal
. One of the primary permitted reasons is nonpayment of premium -if the employer does not pay required premiums within the policy's allowed timeframes (including any required grace period), the carrier may terminate or nonrenew coverage because the group is no longer meeting the contractual payment obligation.
The other options do not typically qualify as valid statutory reasons for nonrenewal in the small group market.
Merely employing fewer than 15 full-time employees is not a trigger for termination (small group status is based on employer size definitions, but size alone doesn't justify cancellation). Filing for bankruptcy is not, by itself, a standard guaranteed-renewability exception. Having supplemental coverage with another carrier also does not allow a carrier to cancel, because employers may coordinate coverage arrangements. Therefore, the only option that matches an allowed discontinuance/nonrenewal basis is failure to pay premiums before the end of the grace period .
NEW QUESTION # 126
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