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Insurance Licensing InsNV_Health02 Exam Syllabus Topics:

Section	Weight	Objectives
Topic 1: Nevada Statutes and Codes Common to Life, Health, Property, and Casualty Insurance	20%	- Nevada Life and Health Insurance Guaranty Association - Licensing 1. Name of licensee 2. Renewal and continuing education 3. Termination of license 4. Suspension, revocation, and refusal of license 5. Obtaining a license 6. Persons required to be licensed - Marketing Practices 1. Required records and record retention 2. Affordable Care Act 3. Silver State Health Insurance Exchange 4. Unfair practices Unfair claims methods and practices and settlement of claims Rebating and inducement Twisting Misrepresentation Fraud Unfair discrimination Defamation 5. Fiduciary responsibilities 6. Commissions and payment restrictions - Definitions 1. Domestic, foreign, and alien 2. Premiums 3. Transacting insurance 4. Cost-sharing 5. Authorized and unauthorized 6. Insurer 7. Certificate of authority - Insurance Commissioner 1. Notice and hearings and penalties 2. General powers and duties 3. Examinations
Topic 2: Nevada Statutes and Codes Common to Life and Health Insurance Only	4%	- Credit life and health insurance - Advertising - Group life and health insurance 1. Eligible groups 2. Required provisions
Topic 3: Accident & Health – General Knowledge	50%	- Social Insurance 1. Medicare Parts A, B, C, and D 2. Medicaid 3. Social Security benefits - Policy Provisions, Clauses, and Riders 1. Other provisions and clauses Insuring clause Free look Consideration clause Probationary period Elimination period Waiver of premium Exclusions and limitations Preexisting conditions Coinsurance Deductibles Eligible expenses Copayments Pre-authorizations and prior approval requirements Usual, reasonable, and customary charges Lifetime, annual, or per cause maximum benefit limits 2. Mandatory and optional provisions Entire contract Time limit on certain defenses Grace period Reinstatement Notice of claim Claim forms Proof of loss Time of payment of claims Payment of claims Physical examination and autopsy Legal actions Change of beneficiary Misstatement of age or gender Change of occupation Illegal occupation Relation of earnings to insurance 3. Riders Impairment and exclusions Guaranteed insurability Future increase option 4. Rights of renewability Noncancelable Cancelable Guaranteed renewable - Other Insurance Concepts 1. Dependent children benefits 2. Modes of premium payments 3. Subrogation 4. Nonduplication and coordination of benefits 5. Primary and contingent beneficiaries 6. Owner's rights 7. Occupational vs. non-occupational 8. Cost containment 9. Workers Compensation 10. Total, partial, recurrent, and residual disability 11. Managed care 12. Tax treatment of premiums and proceeds of insurance contracts - Types of Policies 1. Accidental death and dismemberment 2. Disability income Individual disability income policy Business overhead expense policy Business disability buyout policy Group disability income policy Key employee policy 3. Medicare supplement policies 4. Group insurance Differences between individual and group contracts General characteristics COBRA 5. Other policies Dental Vision Cancer Critical illness or specified disease Worksite employer-sponsored Hospital indemnity Short-term medical Accident 6. Individual and Group Long Term Care Eligibility Levels of care 7. Medical expense insurance Basic hospital, medical, and surgical policies Major medical policies Health Maintenance Organizations Preferred Provider Organizations Point of Service plans Flexible Spending Accounts High Deductible Health Plans and Health Savings Accounts Health Reimbursement Accounts - Field Underwriting Procedures 1. Submitting application and initial premium to company for underwriting 2. Sources of insurability and HIPAA privacy information 3. Contract law Elements of a contract Insurable interest Warranties and representations Unique aspects of the insurance contract 4. Completing the application 5. Replacement 6. Explaining policy provisions, riders, exclusions, and ratings 7. Initial premium payment and receipt 8. Policy delivery
Topic 4: Nevada Statutes and Codes Pertinent to Health Insurance Only	14%	- Mandatory policy clauses and provisions 1. Coverage for newborn children 2. Coverage for physical handicap or intellectual disability for dependent children 3. Coverage for preventive healthcare services - Availability of coverage for mental health and treatment of alcohol abuse and drug abuse - Hospice care - Long Term Care - Coverage for reconstructive surgery - Medicare 1. Medicare supplement regulation 2. Prescription Drug Plan 3. Medicare Advantage Plans

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Insurance Licensing NV Accident and Health InsNV_Health02 Prüfungsfragen mit Lösungen (Q55-Q60):

55. Frage
Which feature is most characteristic of universal life insurance?

A. A fixed premium and fixed death benefit with no flexibility
B. Flexible premiums and adjustable death-benefit options, subject to policy requirements
C. Investment risk borne entirely by the insurer in a separate account
D. Coverage that can never build cash value

Antwort: B

Begründung:
Universal life insurance is a flexible-premium permanent life insurance policy. It generally provides a cash- value account, interest crediting, mortality charges, expense charges, and flexible premium-payment options within policy limits. The owner may often adjust the amount and timing of premiums and may have death- benefit options, subject to minimum funding requirements, underwriting rules for increases, and the policy's terms. The flexibility does not mean the owner can stop paying indefinitely without consequence. If cash value is insufficient to cover monthly deductions and charges, the policy can lapse.
Universal life differs from traditional whole life, which typically has fixed premiums, a guaranteed cash-value schedule, and a fixed death benefit. It also differs from variable life, in which cash value and death benefit are linked to separate-account investments and market performance. Universal life typically uses the insurer's general account for interest crediting, although variable universal life is a separate product combining flexibility with separate-account investment risk.
A producer must explain that illustrated values are not guaranteed unless identified as such. Policyowners should receive in-force illustrations and review funding adequacy periodically, particularly after taking loans, withdrawals, or reducing premium payments.
References/topics from the Study Guide: Universal Life Insurance; Flexible Premiums; Adjustable Death Benefit; Cash Value; Policy Lapse Risk.

56. Frage
Which type of health insurance is designed primarily to reimburse medical expenses such as hospital, surgical, and physician charges?

A. Accidental death insurance
B. Disability income insurance
C. Credit life insurance
D. Medical expense insurance

Antwort: D

Begründung:
Medical expense insurance is designed to reimburse or pay covered health-care expenses arising from illness or injury. These expenses may include hospital room and board, surgical services, physician services, diagnostic testing, outpatient treatment, prescription drugs, and other covered medical care. Benefits are subject to the policy's deductible, copayment, coinsurance, network rules, exclusions, benefit limits, and medical-necessity standards.
Disability income insurance serves a different purpose. It replaces a portion of the insured's earned income when the insured becomes disabled under the policy definition. It does not ordinarily reimburse hospital or physician bills. Accidental death insurance pays a benefit upon qualifying accidental death and does not serve as general medical coverage. Credit life insurance is designed to help satisfy a debt when the debtor dies.
An examination question may describe a policy as basic hospital, surgical, physician expense, major medical, comprehensive major medical, or managed care. Each is within the broader medical-expense category, although benefits and delivery systems differ. The producer should help clients understand the distinction between coverage for medical bills and coverage for lost income. A client can need both forms of protection because medical expenses and inability to earn income are separate financial risks.
References/topics from the Study Guide: Medical Expense Insurance; Hospital Expense; Surgical Expense; Major Medical; Disability Income Insurance.

57. Frage
A group health policy that covers hospital expenses MUST also cover:

A. travel expenses for caretakers
B. elective cosmetic surgery
C. burial expenses
D. routine physical examinations

Antwort: D

Begründung:
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 .

58. Frage
Which feature most clearly distinguishes a health maintenance organization (HMO) from a traditional indemnity health insurance plan?

A. The HMO always reimburses any provider at the same level.
B. The HMO commonly uses a provider network and coordinates care through managed-care rules.
C. The HMO provides only disability-income benefits.
D. The HMO pays only after the insured satisfies a cash-value requirement.

Antwort: B

Begründung:
An HMO is a managed-care arrangement that commonly delivers and finances health-care services through a defined network of providers. Covered persons typically select or are assigned a primary care provider who coordinates routine care and, depending on the plan design, provides referrals for specialist services. Services received outside the network may be limited or not covered except for emergencies or specifically authorized care.
Traditional indemnity insurance operates differently. It generally reimburses covered medical expenses subject to policy limits, deductibles, coinsurance, and usual-and-customary or other payment standards. The insured may have broader provider choice, but that flexibility is often paired with less managed coordination and potentially greater out-of-pocket exposure. A preferred provider organization, or PPO, also uses a network but typically allows nonnetwork care at reduced benefit levels rather than requiring the same referral structure associated with many HMOs.
The exam distinction is based on delivery of care and network control, not merely on whether a policy has a deductible. Managed-care plans seek to control cost and improve coordination by negotiating with providers and establishing coverage procedures. Nevada recognizes network plans as policies in which financing and delivery of medical care are provided, at least in part, through defined providers under contract with the insurer.
References/topics from the Study Guide: Managed Care; HMO; PPO; Network Plans; NRS 689A-Network Plan Definition.

59. Frage
Most insurance companies use the usual, customary, and reasonable (UCR) charges to:

A. limit the insurance company claims liability
B. reimburse the employee for expenses charged by the medical facilities
C. pay dollars direct to the employers for health insurance
D. reimburse physicians for excess expense

Antwort: A

Begründung:
Usual, customary, and reasonable charges are payment standards used to determine the portion of a medical charge that a health insurer recognizes as eligible for reimbursement. Choice D is correct because UCR standards limit the insurer's claim liability to an amount considered appropriate for the service in the relevant geographic area. "Usual" refers to the fee commonly charged by a particular provider; "customary" refers to fees generally charged by comparable providers in the area; and "reasonable" considers the circumstances and complexity of the service. If a provider's charge exceeds the plan's allowed amount, the insurer may pay only the UCR amount, and the patient may remain responsible for the difference unless a network agreement or other policy provision prevents balance billing. UCR does not mean that insurers reimburse excess charges, pay funds to employers, or reimburse every amount billed by a medical facility. This concept is tested as a cost-control mechanism within medical expense coverage and should be distinguished from deductibles, coinsurance, copayments, and maximum benefit limits. Study Guide References/Topics: Policy Provisions, Clauses, and Riders; Medical Expense Insurance; Usual, Customary, and Reasonable Charges.

60. Frage
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