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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Life Insurance Fundamentals | 25-30% | - Dividends and nonforfeiture options - Policy reinstatement - Policy types and provisions - Policy riders and endorsements - Beneficiary designations |
| Topic 2: General Insurance Principles | 15-20% | - Insurance contract fundamentals - Fair claims settlement practices - Ethical sales practices - Agent/broker duties and ethics - Underwriting principles |
| Topic 3: New York State Regulations | 20-25% | - Fiduciary responsibilities - Replacement and churn rules - Licensing requirements and procedures - Advertising regulations - NYS Insurance Law requirements - Consumer protection regulations |
| Topic 4: Accident and Health Insurance | 25-30% | - Major medical coverage - Long-term care insurance basics - Health insurance policy types (individual, group, HMOs) - Dental and vision insurance basics - Medical expense coverage - Disability income insurance |
>> NY-Life-Accident-and-Health Prüfungs-Guide <<
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107. Frage
With regard to Disability Insurance, the waiting period is to
Antwort: C
Begründung:
The correct answer is A. exclude payments for a short-term illness. In disability income insurance, the waiting period , also called the elimination period , is the period of time that must pass after a covered disability begins before benefits become payable. Its primary purpose is to prevent the policy from paying for very brief or temporary disabilities and to reduce the insurer's exposure to small, short-duration claims. Because many minor illnesses or injuries resolve quickly, the waiting period acts like a time deductible rather than a dollar deductible.
This makes choice A the best answer. The waiting period is not used to measure the severity of the illness, so B is incorrect. It is also not intended to calculate medical expenses, because disability insurance pays based on loss of income rather than reimbursement of medical bills, making C incorrect. D is also incorrect because policy eligibility is determined through underwriting and contract terms, not by the waiting period itself.
Therefore, the waiting period in disability insurance is mainly used to exclude benefits for short-term illnesses or disabilities and help keep premiums more affordable.
108. Frage
Under the Affordable Care Act, insurers MUST offer plans within health insurance exchanges that meet distinct levels of coverage. What metal tier is REQUIRED to have an actuarial value of 70% with covered individuals paying 30% through deductibles, co-pays, and other cost sharing features?
Antwort: B
Begründung:
Under the Affordable Care Act (ACA), qualified health plans offered on the individual and small-group exchanges are categorized into metal tiers based on actuarial value (AV) -the percentage of expected average medical costs the plan is designed to pay for a standard population. The ACA's standard tiers are Bronze (60% AV) , Silver (70% AV) , Gold (80% AV) , and Platinum (90% AV) . A plan with a 70% actuarial value is therefore a Silver Plan , meaning that, on average, the insurer pays about 70% of covered healthcare expenses and covered individuals pay about 30% through deductibles, copayments, coinsurance, and other cost-sharing (not including premiums).
This question's wording matches the defining feature of the Silver tier: 70/30 cost-sharing on average . Gold and Platinum tiers have higher actuarial values (so lower expected cost sharing), while Bronze has a lower actuarial value (higher expected cost sharing). Therefore, the required tier at 70% AV is the Silver Plan .
109. Frage
Which of the following is a basic benefit of Medicare Supplemental insurance?
Antwort: B
Begründung:
Medicare Supplement insurance (Medigap) is designed to fill gaps in Original Medicare (Parts A and B) by paying certain out-of-pocket expenses that Medicare does not pay in full. A commonly tested basic Medigap benefit is coverage for the first 3 pints of blood each year . Under Original Medicare, a beneficiary may be responsible for the cost of the first three pints of blood in a calendar year (unless replaced or covered under specific circumstances). Medigap policies include this "first three pints" coverage as part of the standardized core benefits, helping reduce the beneficiary's exposure to unexpected hospital or outpatient blood costs.
The other choices are not considered standard "basic" Medigap benefits. "At-home recovery" and certain
"preventive care" enhancements have been associated with limited or older plan designs rather than being universally basic. "Basic drugs limit of $1,250" reflects older outpatient prescription concepts that are largely associated with pre-Part D benefit structures and not a core Medigap basic benefit in the way the blood coverage is. Therefore, the correct basic benefit is the first 3 pints of blood each year .
110. Frage
When a provider does NOT have an agreement with the insurer for payment, they will be reimbursed
Antwort: B
Begründung:
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.
111. Frage
Which type of group has a constitution and bylaws, is organized and maintained in good faith for purposes other than obtaining insurance, and has insurance for the purpose of covering members and their employees?
Antwort: A
Begründung:
An association or labor group is a type of eligible group used in group insurance arrangements. These groups are typically formed for professional, trade, or labor-related purposes , not primarily to obtain insurance coverage. To qualify for group insurance, such associations must usually meet certain regulatory standards.
These include having a formal organizational structure , such as a constitution and bylaws , and being organized and maintained in good faith for reasons other than purchasing insurance.
The group insurance coverage is then offered to members of the association and often their employees , allowing individuals who share a common professional or labor affiliation to obtain insurance benefits through the association. Because these organizations already exist for legitimate purposes-such as promoting professional interests, labor representation, or trade development-regulators allow them to sponsor group insurance plans.
The other options do not match the description provided. Credit insurance groups relate to loan repayment protection. Multiple employer groups involve several employers joining together to provide coverage, and employee/employer groups are typical workplace plans sponsored by a single employer. The description given specifically fits an association or labor group .
112. Frage
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