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| Section | Weight | Objectives |
|---|---|---|
| Nevada Statutes, Rules and Regulations | ~32% | - Nevada Health-Specific Regulations
|
| Accident and Health — General Knowledge | ~68% | - Social Insurance / Government Plans
|
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NEW QUESTION # 100
The Coinsurance clause in an individual Medical Expense policy refers to the:
Answer: C
Explanation:
Coinsurance is the contractual sharing of covered medical expenses between the insured and the insurer after any applicable deductible has been satisfied. Choice D is correc t. Under a common 80/20 coinsurance arrangement, for example, the insurer pays 80 percent of an eligible expense and the insured pays the remaining 20 percent, up to any out-of-pocket maximum or other plan limitation. Coinsurance reduces premium cost and encourages insureds to consider the cost of care, while preserving significant protection against major expenses. It does not refer to adding family members to a policy, which concerns eligibility or family coverage. It also does not describe insurers sharing risk with each other; that would involve reinsurance or other insurer-to-insurer arrangements. Coinsurance should be distinguished from a deductible, which is a specified dollar amount the insured pays before policy benefits begin. A copayment is instead a fixed dollar amount paid for a covered service. The exact coinsurance percentage, covered-charge definition, network rules, and annual out-of-pocket limit are determined by the policy. Study Guide References/Topics:
Policy Provisions, Clauses, and Riders; Medical Expense Insurance; Deductibles and Coinsurance.
NEW QUESTION # 101
Under a typical coordination-of-benefits rule, a child is covered under both parents' group health plans.
Which plan is generally primary when the parents are married and neither plan contains an exception?
Answer: A
Explanation:
Coordination of benefits, or COB, establishes the order in which multiple health plans pay when an insured is covered by more than one plan. For a dependent child covered by both married parents' group health plans, the common "birthday rule" generally makes primary the plan of the parent whose birthday occurs earlier in the calendar year. The rule compares the month and day of birth, not the year. If both birthdays are the same, the plan that has covered the parent longer is generally primary.
The primary plan pays first according to its own policy terms. The secondary plan then considers the remaining eligible expense and may pay an additional amount, subject to its coordination-of-benefits provision. COB is intended to prevent duplicate recovery exceeding the actual covered expense while still allowing the insured to receive the benefit of multiple coverages.
Special rules can apply in divorce, custody, court-order, active-versus-retired employee, Medicare, and other situations. The producer should never assume that one generic rule governs every family arrangement. Plan documents and applicable law control. For examination purposes, the birthday rule is the standard answer when the parents are married and no special circumstance is stated.
References/topics from the Study Guide: Coordination of Benefits; Primary and Secondary Coverage; Birthday Rule; Group Health Insurance; Dependent Coverage.
NEW QUESTION # 102
In Nevada, a producer or examining physician who knowingly and willfully makes a false statement on an application for insurance may be guilty of:
Answer: D
Explanation:
A producer, examining physician, applicant, or other person who knowingly and willfully makes a false or fraudulent statement or representation in, or in reference to, an insurance application may be guilty of fraud.
Nevada law expressly prohibits this conduct because insurance underwriting depends on truthful and complete information concerning the proposed insured and the risk.
Fraud requires knowing and willful conduct. An innocent clerical error or an inadvertent misunderstanding may require correction, but the exam question describes intentional falsification. Examples can include knowingly misstating medical history, concealing material treatment, falsifying income information in a disability application, or knowingly submitting an untrue medical statement.
Twisting is an improper sales practice involving inducing a policyowner to replace coverage through misleading comparisons or representations. Misrepresentation is a broader term that may describe false statements in insurance transactions, but the statute specifically identifies false or fraudulent application statements as insurance fraud. Coercion involves forcing or improperly pressuring a person to act and is not the conduct described here.
A producer must ensure that application answers are accurately recorded, should not alter answers without authorization, and should promptly correct discovered inaccuracies before policy issuance.
Study Guide references/topics: insurance fraud; applications; producer ethics; prohibited trade practices; NRS
686A.290 .
NEW QUESTION # 103
One key distinction between producers and Exchange Enrollment Facilitator (EEF) is producers:
Answer: B
Explanation:
A licensed producer may recommend a health plan for a consumer because the producer is authorized to sell, solicit, and negotiate insurance. That authority permits the producer to discuss coverage choices in a personalized manner, explain how plan provisions apply to the consumer's situation, and recommend a particular policy or plan when appropriate.
An Exchange Enrollment Facilitator is certified to help consumers enroll in qualified health plans through the Exchange. The EEF role is designed to provide impartial enrollment assistance, application support, and general program information. However, an EEF may not sell, solicit, or negotiate insurance. That restriction prevents an EEF from functioning as an insurance producer or steering a consumer toward a particular carrier or plan.
Explaining general terminology, such as deductibles, copayments, and eligibility rules, can be part of enrollment assistance and is not the defining distinction. Compensation is also not the key answer because the legal distinction turns on insurance authority, not simply whether a person receives payment. A Nevada EEF also may not concurrently hold a producer license.
Study Guide references/topics: Exchange Enrollment Facilitators; producer authority; solicitation and negotiation; NRS Chapter 695J .
NEW QUESTION # 104
A group health policy that covers hospital expenses MUST also cover:
Answer: D
Explanation:
A group health policy that provides hospital-expense coverage must also provide coverage for routine physical examinations. Routine examinations are preventive services intended to identify health concerns early, promote wellness, and reduce the risk that a medical condition will progress before treatment begins.
Burial expenses are not health-insurance benefits. They are ordinarily addressed through life insurance, final- expense coverage, or other arrangements. Elective cosmetic surgery is generally excluded unless it is medically necessary, reconstructive, or otherwise required by the policy or applicable law. Travel expenses for caretakers are likewise not a standard mandatory group health benefit.
The key point is that group health coverage is not confined to hospitalization after illness or injury occurs.
Required provisions can include preventive and health-maintenance benefits. Routine physical examinations allow the insured to receive medical assessment before a condition requires hospital confinement or major treatment.
The exact scope of a routine examination, frequency limitations, network requirements, and whether additional diagnostic services are covered may depend on the policy and applicable preventive-care rules. But among the choices, routine physical examinations are the mandated benefit associated with hospital-expense group coverage.
Study Guide references/topics: group health required provisions; hospital expense coverage; preventive care; routine physical examinations; Nevada group-health policy requirements .
NEW QUESTION # 105
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