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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Nevada Statutes, Rules and Regulations | ~32% | - General State Insurance Regulations
|
| Topic 2: Accident and Health — General Knowledge | ~68% | - Social Insurance / Government Plans
|
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NEW QUESTION # 72
Which policy is designed to pay benefits upon diagnosis or treatment of a specifically named illness, such as cancer?
Answer: A
Explanation:
Specified disease insurance provides limited benefits for a condition or group of conditions specifically named in the policy, such as cancer, heart disease, or stroke. The benefits may be paid as reimbursement for certain covered expenses, as fixed cash amounts for treatment events, or through a schedule of benefits. The scope of coverage is controlled by the policy and is substantially narrower than comprehensive major medical insurance.
A producer must not represent specified disease coverage as complete health insurance. It may help with deductibles, travel, household costs, experimental-treatment expenses not covered elsewhere, or income disruption, but it is not a substitute for comprehensive coverage that addresses a broad range of illnesses and injuries. The client should understand covered conditions, waiting periods, recurrence provisions, preexisting- condition limitations where permitted, benefit schedules, exclusions, and whether the policy pays in addition to other coverage.
Major medical insurance is intended to cover a broad spectrum of medically necessary expenses. Credit disability insurance is connected to repayment of a debt if the debtor becomes disabled. Group term life insurance pays a death benefit and does not provide medical-expense coverage. The examination point is to identify the limited, condition-specific purpose of specified disease insurance.
References/topics from the Study Guide: Specified Disease Insurance; Cancer Insurance; Critical Illness Coverage; Limited-Benefit Health Insurance; Major Medical.
NEW QUESTION # 73
Under a Gold health insurance plan, an insurer would be expected to pay which percentage of medical costs?
Answer: D
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 # 74
Life insurance death proceeds paid to a named beneficiary are generally:
Answer: D
Explanation:
Life insurance death proceeds paid to a named beneficiary are generally excluded from the beneficiary's gross income for federal income-tax purposes. This favorable treatment is one reason life insurance is widely used for family income protection, estate liquidity, business continuation, and debt protection. However, the producer should use the word "generally" because exceptions and special circumstances can affect taxation.
For example, interest paid by the insurer because it retains proceeds under an interest option is generally taxable as interest income. Transfers of a policy for valuable consideration can create a transfer-for-value issue. Business-owned life insurance can involve additional notice, consent, and tax rules. Estate-tax treatment is also separate from income-tax treatment; incidents of ownership or other estate-planning facts may cause proceeds to be included in the insured's taxable estate even though the beneficiary does not owe income tax on the benefit.
Premiums paid for personally owned life insurance are generally not deductible. The producer should not provide individualized tax or legal advice. The proper explanation is that life insurance provides a generally income-tax-favored death benefit, while policy ownership, beneficiary designation, business arrangements, and estate planning should be reviewed with qualified advisers.
References/topics from the Study Guide: Life Insurance Taxation; Death Proceeds; Transfer-for-Value Rule; Estate Tax Concepts; Business-Owned Life Insurance.
NEW QUESTION # 75
Which of the following statements is CORRECT about the Medicaid program?
Answer: B
Explanation:
Medicaid is a means-tested public medical assistance program for eligible low-income individuals and families. Eligibility may include persons who are blind, disabled, aged, pregnant, children, or otherwise within an eligible category under federal and state rules. Therefore, choice A is correct. There is no universal minimum age of 55 for Medicaid eligibility; eligibility is based principally on financial and categorical requirements. Medicaid is also not simply a program supplemented by Medicare at age 62. Medicare eligibility is generally associated with age 65 or qualifying disability or disease status, while Medicaid may assist certain eligible persons with limited income and resources, including some Medicare beneficiaries.
Medicaid is jointly financed by federal and state governments but is administered by the states within federal standards. In Nevada, the state administers the program through its designated health and human-services structure. Examination questions commonly test the distinction between Medicare as social insurance and Medicaid as needs-based medical assistance. Study Guide References/Topics: Social Insurance Programs; Medicaid; Federal-State Health Programs.
NEW QUESTION # 76
An insured has a $1,000 deductible and then pays 20% of covered medical expenses, while the insurer pays
80%. What is the insured's 20% share called?
Answer: A
Explanation:
Coinsurance is the percentage of covered expenses that the insured shares with the insurer after the deductible has been satisfied. In this question, the insured pays 20% and the insurer pays 80%; this is commonly described as 80/20 coinsurance. The deductible is separate. It is the amount the insured must pay before the insurer begins sharing covered expenses, subject to any services that the policy covers before the deductible.
A copayment is a fixed dollar amount paid for a covered service, such as a stated amount for a physician visit or prescription. It is not normally expressed as a percentage. An elimination period is a waiting period in disability-income insurance before benefits begin. A stop-loss feature, also called an out-of-pocket maximum in many plans, limits the insured's covered cost sharing after a stated maximum has been reached, subject to plan rules.
Understanding these terms is essential when comparing health plans. A plan may have a lower premium but a higher deductible, greater coinsurance, or a larger out-of-pocket maximum. Producers must clearly explain the consumer's potential financial responsibility and must not imply that the insurer pays every medical expense once a policy is issued.
References/topics from the Study Guide: Major Medical Insurance; Deductibles; Coinsurance; Copayments; Out-of-Pocket Maximums.
NEW QUESTION # 77
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