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| Section | Objectives |
|---|---|
| Producer Duties and Ethics | - Ethical Responsibilities
|
| General Insurance Regulation | - Licensing Requirements and Responsibilities
|
| Accident and Health Insurance Fundamentals | - Types of Health Insurance Policies
|
| Insurance Basics | - Insurance Contracts
|
| Health Insurance Policy Provisions | - Claims and Benefits
|
| Government Health Insurance Programs | - Medicare
|
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NEW QUESTION # 77
Under a Gold health insurance plan, an insurer would be expected to pay which percentage of medical costs?
Answer: C
Explanation:
A Gold Marketplace health plan has an actuarial value of approximately 80%. Therefore, the insurer is expected to pay about 80% of covered medical costs for a standard population, while enrollees as a group pay approximately 20% through deductibles, copayments, and coinsurance.
Actuarial value does not mean that the insurer pays exactly 80% of every individual's bills. A particular insured may pay more or less than 20% in a year depending on the services used, the plan's deductible, copayment structure, provider network, prescription-drug costs, and whether the annual out-of-pocket maximum has been reached. It is an overall measure of expected cost sharing for covered benefits.
The standard metal levels are Bronze at 60%, Silver at 70%, Gold at 80%, and Platinum at 90%. Gold plans generally have higher monthly premiums than Bronze or Silver plans but lower cost sharing when health care is received. Platinum plans generally have the highest premiums and the lowest cost sharing.
Study Guide references/topics: Affordable Care Act; Marketplace plans; metal levels; actuarial value; deductibles; copayments; HealthCare.gov plan categories .
NEW QUESTION # 78
Which of the following statements is CORRECT about Business Overhead Expense insurance?
Answer: A
Explanation:
Business Overhead Expense insurance reimburses a business for specified ongoing operating expenses when a business owner becomes disabled. Eligible expenses commonly include employee salaries, rent, utilities, office expenses, and other ordinary fixed costs identified in the policy. Accordingly, choice B is correct. The purpose is business continuity: it helps keep the office or practice operating during the owner's disability rather than replacing the owner's personal income. A disability income policy, not Business Overhead Expense insurance, is the product intended to replace an individual's lost earned income. The coverage is not restricted to corporations; it may be appropriate for sole proprietors, partners, and owners of closely held businesses, depending on underwriting and policy eligibility. It also is not limited to staff expenses alone, because rent, utilities, and other contractually covered overhead are central components of the protection.
Benefits are generally limited by the actual covered overhead incurred and the policy's monthly benefit amount. Study Guide References/Topics: Taxation and Business Uses of Health Insurance; Disability Income Insurance; Business Overhead Expense Coverage.
NEW QUESTION # 79
Which of the following statements is correct about the Coordination of Benefits provision?
Answer: D
Explanation:
Coordination of Benefits, commonly called COB, applies when an insured is covered by more than one health plan. It establishes the order in which plans pay and limits the combined payment so the insured does not receive more than the amount of the covered expense. Choice B is correct because COB prevents a profit from duplicate health coverage while still allowing the insured to receive the benefits to which the insured is entitled. One plan is identified as primary and pays first under its policy terms. The secondary plan then considers the unpaid covered balance, subject to its own coordination provisions and limits. COB does not prohibit a person from owning more than one health policy, does not guarantee uninterrupted benefits when changing insurers, and does not authorize a general delay of a workers' compensation claim until benefits expire. Workers' compensation coordination depends on the applicable policy and governing law. On the examination, distinguish COB from nonduplication of benefits and from other insurance clauses; COB specifically allocates payment responsibility among multiple health plans. Study Guide References/Topics:
Group Health Insurance; Coordination of Benefits; Other Insurance Provisions.
NEW QUESTION # 80
Which of the following is true regarding Medicare Advantage Plans?
Answer: C
Explanation:
Medicare Advantage, also called Medicare Part C, is private-plan coverage approved by Medicare. These plans must provide at least the services covered by Original Medicare, subject to Medicare rules, but they may structure deductibles, copayments, and coinsurance differently. For many enrollees, a plan's benefit design can reduce or eliminate certain cost-sharing amounts that would otherwise apply under Original Medicare.
Medicare Advantage plans also include a yearly maximum out-of-pocket limit for covered Medicare services.
Vision, hearing, and dental benefits may be offered as supplemental benefits by many Medicare Advantage plans, but they are not universally mandated as a standard benefit in every plan. Drug coverage is commonly included, but it is not restricted to generic medications only. Part D formularies can include both generic and brand-name drugs, subject to plan rules and Medicare requirements.
The final option is incorrect because an enrollee does not receive a reduced premium merely by opting out of preventive care. Preventive benefits and plan premiums are governed by Medicare and plan design rules rather than by an individual's decision to decline a preventive program.
Study Guide references/topics: Medicare Part C; Medicare Advantage; deductibles; coinsurance; out-of- pocket limits; Medicare Advantage cost rules .
NEW QUESTION # 81
A doctor who is receiving Disability Income benefits is not able to return to work full-time but continues practicing on a part-time basis. Which of the following policy features would allow the doctor to continue receiving benefits?
Answer: A
Explanation:
The correct answer is A. A residual benefit clause permits an insured who has returned to work on a limited basis, but still suffers a loss of income because of disability, to receive partial disability benefits. The doctor is able to practice part-time but cannot resume full-time work, so the disability continues to cause an earnings loss. Residual benefits are intended to encourage rehabilitation and return to productive work without forcing the insured to lose all benefits immediately. The benefit amount is usually tied to the percentage of income lost compared with pre-disability earnings, subject to policy requirements. A contingent benefit clause and concurrent benefit clause are not the standard disability-income provisions that address partial return to work.
A guaranteed insurability rider permits future increases in coverage without proof of insurability; it does not pay benefits for a continuing partial disability. Residual disability should be distinguished from total disability, which generally requires inability to perform the duties defined in the policy. Study Guide References/Topics: Policy Provisions, Clauses, and Riders; Disability Income Insurance; Residual Disability Benefits.
NEW QUESTION # 82
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