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Insurance Licensing InsNV_Health02 Exam Syllabus Topics:

SectionWeightObjectives
Topic 1: Nevada Statutes and Codes Pertinent to Health Insurance Only14%- Medicare
  • 1. Medicare supplement regulation
    • 2. Prescription Drug Plan
      • 3. Medicare Advantage Plans
        - Coverage for reconstructive surgery
        - Mandatory policy clauses and provisions
        • 1. Coverage for preventive healthcare services
          • 2. Coverage for newborn children
            • 3. Coverage for physical handicap or intellectual disability for dependent children
              - Availability of coverage for mental health and treatment of alcohol abuse and drug abuse
              - Long Term Care
              - Hospice care
              Topic 2: Accident & Health – General Knowledge50%- Policy Provisions, Clauses, and Riders
              • 1. 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
              • 2. Rights of renewability
                • Noncancelable
                • Cancelable
                • Guaranteed renewable
              • 3. Riders
                • Impairment and exclusions
                • Guaranteed insurability
                • Future increase option
              • 4. 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
              - Field Underwriting Procedures
              • 1. Replacement
                • 2. Contract law
                  • Elements of a contract
                  • Insurable interest
                  • Warranties and representations
                  • Unique aspects of the insurance contract
                • 3. Policy delivery
                  • 4. Explaining policy provisions, riders, exclusions, and ratings
                    • 5. Submitting application and initial premium to company for underwriting
                      • 6. Initial premium payment and receipt
                        • 7. Completing the application
                          • 8. Sources of insurability and HIPAA privacy information
                            - Social Insurance
                            • 1. Medicare Parts A, B, C, and D
                              • 2. Social Security benefits
                                • 3. Medicaid
                                  - Types of Policies
                                  • 1. Other policies
                                    • Dental
                                    • Vision
                                    • Cancer
                                    • Critical illness or specified disease
                                    • Worksite employer-sponsored
                                    • Hospital indemnity
                                    • Short-term medical
                                    • Accident
                                  • 2. Medicare supplement policies
                                    • 3. Disability income
                                      • Individual disability income policy
                                      • Business overhead expense policy
                                      • Business disability buyout policy
                                      • Group disability income policy
                                      • Key employee policy
                                    • 4. Group insurance
                                      • Differences between individual and group contracts
                                      • General characteristics
                                      • COBRA
                                    • 5. Individual and Group Long Term Care
                                      • Eligibility
                                      • Levels of care
                                    • 6. 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
                                    • 7. Accidental death and dismemberment
                                      - Other Insurance Concepts
                                      • 1. Workers Compensation
                                        • 2. Modes of premium payments
                                          • 3. Primary and contingent beneficiaries
                                            • 4. Cost containment
                                              • 5. Dependent children benefits
                                                • 6. Total, partial, recurrent, and residual disability
                                                  • 7. Tax treatment of premiums and proceeds of insurance contracts
                                                    • 8. Occupational vs. non-occupational
                                                      • 9. Subrogation
                                                        • 10. Owner's rights
                                                          • 11. Nonduplication and coordination of benefits
                                                            • 12. Managed care
                                                              Topic 3: Nevada Statutes and Codes Common to Life, Health, Property, and Casualty Insurance20%- Marketing Practices
                                                              • 1. Required records and record retention
                                                                • 2. Silver State Health Insurance Exchange
                                                                  • 3. Affordable Care Act
                                                                    • 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
                                                                        - Licensing
                                                                        • 1. Name of licensee
                                                                          • 2. Termination of license
                                                                            • 3. Obtaining a license
                                                                              • 4. Suspension, revocation, and refusal of license
                                                                                • 5. Persons required to be licensed
                                                                                  • 6. Renewal and continuing education
                                                                                    - Insurance Commissioner
                                                                                    • 1. Notice and hearings and penalties
                                                                                      • 2. Examinations
                                                                                        • 3. General powers and duties
                                                                                          - Nevada Life and Health Insurance Guaranty Association
                                                                                          - Definitions
                                                                                          • 1. Transacting insurance
                                                                                            • 2. Premiums
                                                                                              • 3. Insurer
                                                                                                • 4. Certificate of authority
                                                                                                  • 5. Domestic, foreign, and alien
                                                                                                    • 6. Authorized and unauthorized
                                                                                                      • 7. Cost-sharing
                                                                                                        Topic 4: Nevada Statutes and Codes Common to Life and Health Insurance Only4%- Advertising
                                                                                                        - Group life and health insurance
                                                                                                        • 1. Required provisions
                                                                                                          • 2. Eligible groups
                                                                                                            - Credit life and health insurance

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                                                                                                            Insurance Licensing NV Accident and Health Sample Questions (Q91-Q96):

                                                                                                            NEW QUESTION # 91
                                                                                                            What is the principal purpose of Medicare supplement insurance?

                                                                                                            Answer: D

                                                                                                            Explanation:
                                                                                                            Medicare supplement insurance, often called Medigap, is designed to help pay certain out-of-pocket costs left by Original Medicare, such as deductibles, coinsurance, copayments, and other covered gaps, depending on the standardized policy type and current rules. It supplements Original Medicare Parts A and B; it does not replace Medicare coverage. The insured must generally remain enrolled in Original Medicare to use a Medicare supplement policy.
                                                                                                            Medigap differs from Medicare Advantage. A Medicare Advantage plan is a private plan through which an eligible beneficiary receives Medicare-covered services, usually with plan networks, plan rules, and an annual out-of-pocket maximum. A consumer generally does not use a Medicare supplement policy to supplement a Medicare Advantage plan. Medigap also differs from stand-alone Part D prescription-drug coverage, which is separately arranged for many Original Medicare beneficiaries.
                                                                                                            Producers selling Medicare-related products must make accurate comparisons, use required disclosures, and avoid misleading consumers about benefits, provider access, premiums, or enrollment rights. A client's health needs, travel patterns, provider preferences, prescription needs, affordability, and enrollment timing are important factors. No single Medicare arrangement is automatically best for every beneficiary.
                                                                                                            References/topics from the Study Guide: Medicare Supplement Insurance; Original Medicare; Medicare Advantage; Medicare Part D; Medicare Cost Sharing.


                                                                                                            NEW QUESTION # 92
                                                                                                            J and K are married and have several children. J is the primary beneficiary on K ' s Accidental Death and Dismemberment (AD & D) policy, and K ' s sibling, L, is the contingent beneficiary. J, K, and L are involved in a train accident, and K and L are killed instantly. The Accidental Death benefits will be paid to:

                                                                                                            Answer: A

                                                                                                            Explanation:
                                                                                                            The correct answer is D, J only. A primary beneficiary has the first right to receive policy proceeds. J is named as K's primary beneficiary and survives the accident. Therefore, the AD & D benefit is paid directly to
                                                                                                            J. The contingent beneficiary, L, would receive the proceeds only if the primary beneficiary had died before K or could not receive the benefit under the policy terms. Because J remains alive, L's death does not change the payment outcome. The proceeds do not pass to K's estate because a living named primary beneficiary exists.
                                                                                                            They also do not pass to L's estate, because L never became entitled to the benefit; the contingency never occurred. Beneficiary designations control over general assumptions about family relationships or estates. The insured should keep beneficiary designations current after changes in family status, death, divorce, or estate- planning decisions. A simultaneous-death provision can alter outcomes if the beneficiary and insured die in the same event and survivorship cannot be determined, but the facts here identify K and L as deceased while J survives. Study Guide References/Topics: Group Health Insurance; Accidental Death and Dismemberment; Beneficiary Designations.


                                                                                                            NEW QUESTION # 93
                                                                                                            A policyowner names two children as beneficiaries "per stirpes." If one child dies before the insured but leaves children, how are that deceased child's share and the surviving child's share handled?

                                                                                                            Answer: C

                                                                                                            Explanation:
                                                                                                            A per stirpes beneficiary designation means "by the branch" or "by the bloodline." If a named beneficiary dies before the insured, that beneficiary's descendants take the deceased beneficiary's share. In this question, the deceased child's children receive the share that would have gone to their parent, while the surviving child receives that child's own share. This preserves each family branch's intended portion of the life insurance proceeds.
                                                                                                            A per capita designation works differently. Under a per capita arrangement, surviving members of a named class generally share equally, and a deceased beneficiary's descendants do not automatically take the deceased beneficiary's share unless the designation or policy language provides otherwise. The precise result always depends on the policy designation, applicable law, and any contingent- beneficiary provisions.
                                                                                                            Beneficiary designations should be reviewed after divorce, marriage, birth, death, adoption, or other major changes. A producer should not provide legal advice about estate planning, but should encourage the policyowner to obtain professional legal guidance when the designation involves trusts, minors, estates, complex family arrangements, or special-needs planning.
                                                                                                            The test point is straightforward: per stirpes preserves the deceased beneficiary's branch; per capita distributes among the surviving members of the class.
                                                                                                            References/topics from the Study Guide: Beneficiary Designations; Per Stirpes; Per Capita; Primary and Contingent Beneficiaries; Estate Planning Basics.


                                                                                                            NEW QUESTION # 94
                                                                                                            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: B

                                                                                                            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 # 95
                                                                                                            Which of the following information is included in the Consideration clause in an Accident and Health policy?

                                                                                                            Answer: C

                                                                                                            Explanation:
                                                                                                            The consideration clause identifies the exchange of value that creates the insurance contract. The insurer's consideration is its promise to provide the stated coverage and pay covered claims. The applicant's consideration consists of the application statements and payment of the required premium. Therefore, choice D is correct because the policy identifies the schedule and amount of premium payments as part of that contractual consideration. The coverage description is found in the insuring clause and benefit provisions.
                                                                                                            Contestability is addressed in the time-limit or incontestability provisions. The grace period is stated in a separate mandatory policy provision dealing with late premium payments and continuation of coverage. The consideration clause is important because it establishes that insurance is a reciprocal exchange: the insurer assumes risk in return for the applicant's premium and representations. If the premium is not paid as required, the policy can lapse after the grace period unless another provision applies. The clause also connects the policy and attached application as part of the entire contract, subject to applicable individual accident and health insurance requirements. Study Guide References/Topics: Policy Provisions, Clauses, and Riders; Consideration Clause; Entire Contract.


                                                                                                            NEW QUESTION # 96
                                                                                                            ......

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