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| Section | Objectives |
|---|---|
| Topic 1: Producer Duties and Ethics | - Ethical Responsibilities
|
| Topic 2: Government Health Insurance Programs | - Medicaid and Other Programs
|
| Topic 3: Insurance Basics | - Risk Management and Insurance Concepts
|
| Topic 4: General Insurance Regulation | - Nevada Insurance Department and Regulatory Authority
|
| Topic 5: Accident and Health Insurance Fundamentals | - Disability Income Insurance
|
| Topic 6: Health Insurance Policy Provisions | - Mandatory and Optional Provisions
|
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NEW QUESTION # 88
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 # 89
Most insurance companies use the usual, customary, and reasonable (UCR) charges to:
Answer: B
Explanation:
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.
NEW QUESTION # 90
An applicant submits the first premium with a life insurance application and receives a conditional receipt.
When does coverage generally become effective?
Answer: A
Explanation:
A conditional receipt may provide temporary coverage from the application date or medical-examination date, but only if the conditions stated in the receipt are satisfied. A common condition is that the insurer, applying its normal underwriting standards, would have issued the policy to the applicant as applied for or at the requested rating. The receipt does not guarantee coverage for every applicant merely because the first premium was submitted.
The exact effect of a conditional receipt depends on its language. Some receipts use an "approval" approach, under which coverage begins only when the insurer approves the application. Others use an "insurability" approach, under which coverage may relate back to an earlier date if the applicant was insurable under the insurer's standards. A producer must not describe a conditional receipt as an unconditional binder or promise that the policy has been issued.
The producer should collect and transmit premium funds according to insurer instructions, deliver the receipt, explain its limited nature, and avoid making coverage representations outside the receipt's terms. If the insurer declines the application, the premium is ordinarily returned according to the applicable procedure.
Proper explanation is especially important because applicants may assume that payment alone creates permanent insurance.
References/topics from the Study Guide: Conditional Receipt; Premium with Application; Temporary Insurance; Underwriting Approval; Policy Delivery.
NEW QUESTION # 91
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 # 92
A Nevada producer wants to solicit an individual disability-income policy. Which license authority is required?
Answer: D
Explanation:
A producer soliciting an individual disability-income policy must hold Nevada accident and health insurance authority. Nevada defines this line as insurance for sickness, bodily injury, or accidental death and permits it to include disability-income benefits. Disability-income insurance replaces a portion of earned income when an insured becomes disabled under the policy definition; it is therefore within the accident-and-health line rather than the property, casualty, or personal-lines authorities.
Nevada requires a person to be licensed for the relevant class of insurance before selling, soliciting, or negotiating insurance in the state. The licensing distinction matters because a life authority and an accident- and-health authority are separately identified lines of authority. Although life insurance may include additional disability-income benefits when permitted as part of its statutory definition, a producer selling an individual health or disability-income policy should not assume that life authority alone authorizes the transaction.
The producer must also comply with appointment requirements when acting as an insurer's agent, continuing education and renewal requirements, and all applicable trade-practice rules. Selling without the proper authority can result in administrative discipline and a monetary penalty. On examination questions, identify the coverage being sold first; then match it to the appropriate Nevada line of authority.
References/topics from the Study Guide: Producer Licensing; Lines of Authority; Accident and Health Insurance; Disability Income; NRS 683A.201; NRS 683A.261.
NEW QUESTION # 93
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