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| Section | Objectives |
|---|---|
| Topic 1: Insurance Fundamentals | - Principles of insurance and risk management
|
| Topic 2: Accident and Health Insurance | - Policy features and provisions
|
| Topic 3: State Regulations (New York) | - Ethics and compliance
|
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NEW QUESTION # 112
When a provider does NOT have an agreement with the insurer for payment, they will be reimbursed
Answer: A
Explanation:
When a medical provider does not have a contract or payment agreement with an insurer (often called a nonparticipating or out-of-network provider), the insurer generally does not pay based on a negotiated contract rate. Instead, reimbursement is commonly determined using a UCR methodology- Usual, Customary, and Reasonable charges. "Usual" refers to the typical charge a provider makes for a service;
"customary" reflects what providers in the same geographic area commonly charge for that service; and
"reasonable" considers whether the charge is appropriate given the circumstances and local market norms.
Under many major medical plans, the insurer pays a percentage of the UCR amount (subject to deductibles and coinsurance), and the patient may be responsible for any difference between the provider's billed charge and the insurer's allowed UCR amount (often referred to as balance billing , where permitted).
The other choices do not match standard insurer payment terminology: "absolute" and "relative" fee are not the typical reimbursement basis described for noncontracted providers, and "non-scheduled plan customary fee" is not the recognized standard method used in these plan provisions.
NEW QUESTION # 113
Which of the following statements BEST describes a single premium cash value policy?
Answer: B
Explanation:
A single premium cash value life insurance policy is a form of permanent insurance that is fully funded with one lump-sum premium payment at the time of purchase. After that single payment is made, the policy is considered paid-up , meaning no additional premiums are required to keep the coverage in force for the policy' s duration (as long as no loans/withdrawals or other actions cause lapse). Because it is permanent insurance, it is designed to build cash value , and the death benefit remains in effect subject to the contract terms.
Option B is incorrect because "only one premium without evidence of insurability" describes a guaranteed insurability-type concept, not single premium funding; single premium policies still require underwriting at issue. Option C describes a waiver of premium benefit (typically waiving premiums during disability), not a single premium policy. Option D describes an annual premium mode (payment frequency), not a one-time premium. Therefore, the best description is that it requires only one payment to make the policy paid up.
NEW QUESTION # 114
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 # 115
A Section 457 Deferred Compensation plan is provided specifically for employees of
Answer: C
Explanation:
A Section 457 Deferred Compensation Plan is a type of retirement savings program established under Section
457 of the Internal Revenue Code. It is primarily designed for employees of state and local governments , including workers employed by states, counties, cities, and municipalities , as well as certain governmental agencies. These plans allow employees to defer a portion of their salary into a retirement account on a pre-tax basis , meaning the contributions are not included in taxable income until the funds are withdrawn, usually during retirement.
Section 457 plans are similar in concept to other tax-deferred retirement plans such as 401(k) or 403(b) plans, but they are specifically intended for public sector employees . One of the distinctive features of a governmental 457 plan is that withdrawals can often be taken without the early withdrawal penalty typically applied before age 59ยฝ , provided the participant separates from service.
Options such as sole proprietorships or religious organizations typically use other retirement arrangements (like SEP, SIMPLE IRA, or 403(b) plans ). Therefore, the correct answer is that Section 457 plans are intended for employees of states, counties, or municipalities .
NEW QUESTION # 116
The difference between the face value of a life insurance policy and its cash value is the
Answer: C
Explanation:
The correct answer is C. net amount. In life insurance, the difference between a policy's face amount and its cash value is commonly referred to in licensing terminology as the net amount at risk , and exam questions often shorten that phrase to net amount . This represents the portion of the death benefit the insurer is actually risking at a given time because the cash value already belongs to the policyowner and offsets part of the insurer's exposure. As cash value increases over the life of a permanent policy, the insurer's net amount at risk generally decreases. NAIC life insurance regulatory material describes the amount subtracted from the policy's face value to determine the net amount at risk , which is consistent with this concept. ( NAIC ) The other options are not correct insurance terms for this relationship. Market value applies more to investments or securities. Assumed amount is not the standard term used in life insurance contract analysis.
Term value is also incorrect because term insurance generally does not build cash value. Therefore, the recognized answer is net amount , meaning the policy's net amount at risk . ( NAIC )
NEW QUESTION # 117
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