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| Section | Weight | Objectives |
|---|---|---|
| Underwriting, Marketing and Sales Practices | 15% | - Sales and Customer Service
|
| Life Insurance Products and Provisions | 30% | - Policy Provisions, Riders and Options
|
| Accident and Health Insurance | 35% | - Policy Provisions and Claims
|
| Insurance Regulation and General Principles | 20% | - New York Insurance Code and Laws
|
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NEW QUESTION # 24
When a provider does NOT have an agreement with the insurer for payment, they will be reimbursed
Answer: B
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 # 25
Sue Ellen is the sister of a licensed New York insurance producer, Frank Gillespie. Frank was recently killed in a car accident and Sue Ellen has been issued a temporary license to run Frank ' s agency. For what period of time is the initial temporary license valid?
Answer: D
Explanation:
New York allows the Department to issue a temporary insurance producer license when a licensed producer dies or becomes disabled, so that the producer's business can continue operating while ownership is settled, policies are serviced, and clients are not disrupted. The temporary license is typically issued to a qualified person (often a spouse, family member, employee, or legal representative) to supervise and operate the agency for a limited time, even if that person is not otherwise licensed in the same lines.
Under New York licensing rules tested in producer education materials, the initial temporary license period is
6 months . This limited duration reflects that the temporary authority is meant to be short-term-long enough to arrange sale, transfer, or appointment of a properly licensed replacement-rather than a substitute for full licensure. Depending on circumstances and Department approval, extensions may be possible, but the question asks specifically for the initial validity period. Therefore, the correct period for the initial temporary license is 6 months .
NEW QUESTION # 26
Which type of policy pays an amount per day for hospitalization directly to the insured regardless of the insured ' s other health insurance?
Answer: C
Explanation:
The correct answer is Hospital indemnity . A hospital indemnity policy is a form of limited benefit health insurance that pays a fixed dollar amount for each day the insured is confined in a hospital. The benefit is paid directly to the insured , not necessarily to the hospital or physician, and it is paid regardless of any other health insurance coverage the insured may have. This means the insured may use the money for hospital bills, deductibles, coinsurance, lost income, transportation, or any other expenses resulting from illness or injury.
This type of policy differs from major medical insurance, which reimburses covered medical expenses subject to deductibles, copayments, and policy limits. It also differs from Medigap , which is designed specifically to supplement Medicare, and from blanket coverage , which insures groups without naming specific individuals.
Although "limited-amount per diem" describes a style of benefit, the established policy name used in licensing materials for a daily hospitalization benefit paid directly to the insured is hospital indemnity .
Therefore, the policy that pays a stated daily amount for hospitalization regardless of other coverage is A.
Hospital indemnity .
NEW QUESTION # 27
An insurer monitors the care an insured is receiving in the hospital to be sure that everything is proceeding according to schedule. This BEST describes
Answer: C
Explanation:
This situation describes concurrent review , a type of utilization management performed while the insured is actively receiving care , such as during an inpatient hospital stay. In concurrent review, the insurer (or its utilization review organization) monitors the ongoing treatment plan to confirm that services remain medically necessary , appropriate in intensity, and consistent with expected treatment timelines (for example, whether continued hospitalization is justified or whether discharge planning is appropriate). This differs from precertification (prior authorization) , which occurs before a service is provided to approve planned hospitalization, procedures, or certain high-cost services. It also differs from claims adjudication , which is the process of evaluating a submitted claim after services are rendered to determine payable benefits under the policy (applying deductibles, coinsurance, exclusions, and coverage limits). "Benefit checking" is not the standard term used for this managed care function. Because the question emphasizes monitoring care "in the hospital" and ensuring it proceeds according to schedule during the stay, the best match is concurrent review .
NEW QUESTION # 28
The policy provision describing the responsibilities of the master policyowner is in
Answer: D
Explanation:
The correct answer is A. group health policies . In a group health insurance plan , the actual contract is issued to the master policyowner , usually an employer, association, or trust. Because that party owns the master contract, the policy contains provisions describing the policyowner's responsibilities, such as premium remittance, eligibility administration, enrollment procedures, and notice requirements. Those duties belong in the group policy itself , not in the individual evidence given to insured members.
A certificate of coverage is provided to each covered employee or member to summarize benefits, exclusions, and rights under the group plan, but it is not the master contract and does not serve as the document that sets out the policyowner's contractual responsibilities. Choices C and D are incorrect because individual health or individual medical policies are issued directly to an individual policyowner, so there is no separate "master policyowner" structure as found in group insurance.
On licensing examinations, whenever the question refers to the master policyowner , it is a strong indicator that the subject is group insurance , making group health policies the correct choice.
NEW QUESTION # 29
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