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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: General Insurance Principles | 15-20% | - Ethical sales practices - Insurance contract fundamentals - Underwriting principles - Agent/broker duties and ethics - Fair claims settlement practices |
| Topic 2: Life Insurance Fundamentals | 25-30% | - Policy reinstatement - Policy types and provisions - Policy riders and endorsements - Beneficiary designations - Dividends and nonforfeiture options |
| Topic 3: Accident and Health Insurance | 25-30% | - Disability income insurance - Health insurance policy types (individual, group, HMOs) - Dental and vision insurance basics - Long-term care insurance basics - Major medical coverage - Medical expense coverage |
| Topic 4: New York State Regulations | 20-25% | - Advertising regulations - Licensing requirements and procedures - Consumer protection regulations - Replacement and churn rules - NYS Insurance Law requirements - Fiduciary responsibilities |
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NEW QUESTION # 112
Under the Affordable Care Act, an insurer may place dollar limits on coverage for
Answer: D
Explanation:
The correct answer is D. routine adult dental services. The Affordable Care Act (ACA) prohibits health insurers from placing lifetime or annual dollar limits on coverage for Essential Health Benefits (EHBs) .
These essential health benefits include services such as laboratory services, mental health and substance use disorder services, and maternity and newborn care . Because these categories are designated as essential health benefits, insurers are not allowed to impose annual or lifetime dollar caps on them under ACA- compliant health plans.
However, routine adult dental services are not included in the ACA's list of essential health benefits . While pediatric dental services are included as an essential health benefit category, routine dental coverage for adults is generally offered as an optional or separate benefit. Because it is not classified as an essential health benefit under the ACA, insurers may legally apply dollar limits or other coverage limitations to routine adult dental services depending on the policy design.
Therefore, under ACA regulations applicable to health insurance policies and marketplace plans beginning in
2014, dollar limits are prohibited for essential health benefits but may still apply to non-essential benefits , such as routine adult dental care .
NEW QUESTION # 113
Some states have laws ensuring that health insurance coverages are available at a reasonable cost and under reasonable conditions for small employers. Small employers are defined as having no more than
Answer: B
Explanation:
The correct answer is 100 employees . In accident and health insurance licensing material, "small employer" or "small group" generally refers to an employer with 1 to 100 employees for purposes of small-group health insurance market rules. These laws are intended to make coverage more available and affordable for smaller businesses that may not have the bargaining power of large employers. They are commonly associated with protections involving availability of coverage, renewal standards, rating limitations, and fair underwriting conditions in the small-group market.
This question tests recognition of the standard upper limit used in modern health insurance regulation for a small employer group. The other options-75, 150, and 200-do not match the commonly tested definition.
In exam context, the purpose is to distinguish small-group health coverage from large-group coverage, because different rules may apply to eligibility, premium determination, and mandated access. So, when a health insurance question asks how many employees a "small employer" may have under these types of laws, the expected answer is no more than 100 employees .
NEW QUESTION # 114
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: D
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 # 115
On or after January 1, 2014, employers with no more than 25 full time equivalent employees (FTEs) with average annual wages of less than $50,000 may be eligible for a tax credit of up to how much of the premiums paid by the employer?
Answer: C
Explanation:
Beginning January 1, 2014 , the Affordable Care Act (ACA) expanded the Small Employer Health Insurance Tax Credit to encourage small employers to offer health coverage. Under the post-2014 rules referenced in licensing materials, an eligible small employer with no more than 25 full-time equivalent (FTE) employees and average annual wages under $50,000 may qualify for a credit of up to 50% of the employer's premium contribution (with a lower maximum generally applying to eligible tax-exempt employers). The credit is designed to offset part of the cost of providing group health insurance, and eligibility and the credit amount depend on meeting the size and wage thresholds and contributing toward employee premiums.
The maximum percentage is important: 50% is the "up to" cap used for small employers under the ACA framework on or after 2014, making option C correct. The other options are distractors because they understate or overstate the statutory maximum credit percentage available to qualifying small employers during that period.
NEW QUESTION # 116
Which of the following statements BEST describes a single premium cash value policy?
Answer: C
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 # 117
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