Accident and Health Insurance Producer Examination

1.Mara Ellison is a violinist covered by an own-occupation disability policy. She can still teach music classes, but she cannot play the violin. When does this definition pay a total disability benefit?

2.Jonah Peck can no longer work as a roofer, but he can do indoor sales work that fits his experience. His disability policy uses an any-occupation definition. What is the result?

3.Priya Raman is totally disabled for 70 days and then returns to full duty. Her disability policy has a 90-day elimination period and a five-year benefit period. What does the elimination period do in this claim?

4.Luis Ortega has already satisfied the elimination period and remains totally disabled. His policy lists a benefit period to age 65. What does that benefit period limit?

5.Helen Cho returns to her design firm part time after a covered disability. She is working, but her monthly earnings are much lower than before. Her policy includes residual disability. What can that benefit do?

6.Andre Walsh dies of a sudden illness. His only policy in this claim is accidental death and dismemberment. How does that policy respond to the death?

7.Naomi Brooks loses one hand in a covered accident and survives. Her accidental death and dismemberment policy lists a capital sum for that loss. What is payable under this policy?

8.Caleb Frost is an inpatient for four days. The hospital bill is $22,000. He owns a hospital indemnity policy that pays $250 for each day confined. What does this policy pay?

9.Denise Park wants cash she can use for household costs while she is hospitalized. She does not want a policy that pays the hospital based on the size of the bill. Which policy fits that goal?

10.Omar Haddad will use only contracted doctors and hospitals, and he will choose a primary doctor to coordinate care, in exchange for a managed-care plan. Which arrangement matches?

11.Ruth Keller sees a specialist outside her plan network. The plan still pays part of the allowed amount, but it pays a larger share in network. She did not need a referral. Which plan behaves this way?

12.Simon Blake must use a primary doctor for in-network care. He may also leave the network if he accepts a lower payment from the plan. Which design is this?

13.During the policy term, the insurer gives Elena Voss written notice that it is ending her individual health policy, as the contract permits, and it returns unearned premium. What renewability is this?

14.Marcus Hale's disability policy must be renewed until age 65. The insurer may raise the rate for the whole class, but not because Marcus alone filed claims. What is this renewability?

15.Ingrid Solano's disability policy guarantees that it will be renewed to age 65 and that her premium will stay the same. What is that combination called?

16.Pete Navarro enrolls in an ACA-compliant individual major medical plan. He was treated for asthma last year. May this plan exclude the asthma as a pre-existing condition?

17.Camille Ortiz applies for an individual disability income policy. She had back surgery four months ago. Which statement is correct?

18.Wesley Grant is admitted as an inpatient for a covered hospital stay under Original Medicare. Which part is the hospital part?

19.Farah Quinn has a covered outpatient visit with her doctor under Original Medicare. Which part is the medical part that helps with that visit?

20.Todd Brennan enrolls in a private plan that provides his Medicare Part A and Part B benefits and uses a provider network. He is no longer paid under Original Medicare's method. Which part is that plan?

21.Ida Moreau wants Medicare coverage that helps pay for outpatient prescription drugs at a pharmacy. Which part is designed for that role?

22.Lila Chen keeps Original Medicare Parts A and B. She buys a private policy whose role is to help pay deductibles and coinsurance that Original Medicare does not pay. What did she buy?

23.A client asks whether a Medicare Supplement policy is simply another name for a Medicare Advantage plan. How should the producer answer?

24.Hugo Martinez asks what can trigger benefits under a long-term care policy. Which answer is sound without claiming that every policy uses the same count?

25.Edith Lang can still bathe and dress, but severe dementia means she cannot safely be left alone. Her long-term care policy includes a cognitive-impairment trigger. What can follow?

26.Nina Alvarez is laid off and loses active coverage under her employer's group health plan. She is a qualified beneficiary and elects COBRA. What does COBRA allow her to do?

27.Benito Cruz elects COBRA after his employment is terminated and his group health coverage would otherwise end. What continuation period commonly applies to that event?

28.Imani Shah is covered by two employer group health plans. The plans must not together pay more than the covered medical expense. What is this rule called?

29.An individual health policy was issued with the application attached, plus a later rider that the insurer added in writing. Under the entire-contract provision, what is the contract?

30.How long is the time limit on certain defenses in an individual accident and health policy?

31.A premium due date passes and the owner has not yet paid. The policy stays in force for a stated extra time so the premium can still be paid. Which provision is operating?

32.A lapsed individual health policy is reinstated under the required reinstatement provision. Which statement about new coverage is accurate?

33.What does the notice-of-claim provision require the insured to do?

34.After receiving notice of a claim, what does the claim-forms provision require the insurer to do?

35.What does the proof-of-loss provision commonly require?

36.A disability income claim has been proved, and benefits are payable over time. Under the time-of-payment provision, how often must those periodic benefits be paid?

37.Renee Oswald had named her brother as beneficiary of an accidental death benefit. She dies in a covered accident. Who is paid that loss-of-life amount?

38.While a health claim is pending, what may the insurer do under the physical-exam and autopsy provision?

39.An insured wants to sue on an individual accident and health policy. Under the legal-actions provision, when may that suit commonly be brought?

40.Harun Ellis reserved the right to change the beneficiary of his accidental death benefit. He files a written request with the insurer naming his daughter. When does the change take effect?

41.Which of these is an optional policy provision rather than a uniform required provision?

42.Devon Clark changes from a desk job to structural steel work, a more hazardous occupation. His disability policy includes a change-of-occupation provision. If a covered disability then occurs, what commonly happens?

43.Sonia Patel stated the wrong age on her accident and health application. The insurer discovers the error when she files a claim. The policy includes the misstatement-of-age provision. What is the usual result?

44.Glen Harper has two disability policies with the same insurer, and the combined monthly benefit is above the maximum that insurer allows. Both policies include the other-insurance-in-this-insurer provision. What can that insurer do?

45.Dr. Leena Bakker's policy pays total disability if she cannot perform surgery, even though she could still teach in a clinic. Which definition does that policy use?

46.Samir Dalal's policy pays total disability only if he cannot perform work that fits his schooling and job history, not merely because he left his warehouse job. Which definition is that?

47.A disability policy says that, once the waiting time is over, benefits can be paid for up to two years. Which term names that two-year limit?

48.Chris Adler becomes disabled on March 1. The disability policy has a 60-day elimination period and no other waiting rule. If Chris remains disabled, when can income benefits begin?

49.Robin Estes's policy pays residual disability as the percent of income lost times a $5,000 monthly benefit. Prior income was $10,000 and current income is $6,000. What is payable this month?

50.Miguel Santos loses hearing in both ears from a listed accidental injury. He has an accidental death and dismemberment policy that schedules that loss. What does the policy pay?

51.Paula Hendricks dies in a covered automobile accident. Her accidental death benefit lists a principal sum of $80,000. Sickness was not involved. What is payable under that benefit?

52.Yuri Petrov's policy pays $300 for each day of hospital confinement and pays nothing toward surgeon fees. He is confined for three days. The hospital bill is $9,400. What does this policy pay?

53.Aisha Benton belongs to a typical HMO and wants a nonemergency office visit with a cardiologist. What does that plan generally require?

54.Diane Fowler uses an out-of-network clinic for a covered, nonemergency service under her PPO. Compared with the same service in network, what should she expect?

55.Cole Ishikawa is in a point-of-service plan. He skips the network for a routine visit and accepts a higher personal cost. How does the plan treat that visit?

56.A major medical plan makes the insured pay a $1,000 deductible, then the plan pays 80 percent of the remaining covered charges. A covered bill is $6,000, and nothing has been credited to the deductible. How much does the plan pay?

57.An insured has already reached the plan's $3,500 out-of-pocket maximum for covered in-network care this year. A new covered in-network bill of $2,200 arrives. What does the plan pay toward that bill?

58.In a major medical plan, what is the deductible?

59.Nora Feldman pays a flat $40 at an in-network office visit, and the plan pays the rest of the allowed charge for that visit. What is the $40?

60.After the deductible, a medical plan pays 70 percent of covered charges and the member pays 30 percent. What is the member's 30 percent called?

61.Pauline Greer needs long-term help only with bathing and dressing. She does not need skilled medical care. How does Original Medicare treat that custodial care?

62.May an ACA-compliant major medical plan place a lifetime dollar cap on essential health benefits?

63.An in-network screening is on an ACA-compliant major medical plan's list of preventive services. How is member cost sharing generally handled?

64.An ACA-compliant major medical plan covers dependent children. Until what age must that dependent coverage generally remain available?

65.Who holds the master contract in an employer group health plan?

66.What does an employee covered by a group health plan typically receive as evidence of coverage?

67.An employer pays the entire group health premium, and coverage is provided to the eligible employees without employee contributions. What kind of plan is this?

68.Employees pay part of the group health premium by payroll deduction, and the employer pays the rest. What is this arrangement called?

69.A group health plan says a new employee must be actively at work on the day coverage is to start. Why is that requirement used?

70.How does underwriting of a large employer health group commonly differ from underwriting of an individual disability income policy?

71.Owen Briggs's new disability policy covers accidents from the issue date, but it does not cover sickness that begins in the first 30 days. What is that opening limit on sickness called?

72.Which statement correctly separates two different timing rules in a disability income policy?

73.Malik Jordan recovers from a covered disability, then the same condition disables him again within the six months stated in the policy. The clause says no new elimination period applies. What is this clause about?

74.Joan Keene totally and permanently loses sight in both eyes. Many disability policies treat that loss as a presumptive disability. What does that treatment commonly mean?

75.Victor Almasi cannot perform one main duty of his job but can perform the others. A rider pays 50 percent of the total disability benefit for up to six months and does not measure his income loss. What is that benefit?

76.Thea Morgan has been disabled long enough to meet her disability policy's qualifier. The insurer stops charging premium and keeps the coverage in force. Which provision does this?

77.Eli Okonkwo's health policy pays for an injury that happens away from work and excludes injuries that workers' compensation covers. What is that coverage called?

78.Rosa Bennett is hurt while doing her paid job as a line cook. Workers' compensation covers the injury, and her group health plan excludes work injuries. Which payer is responsible for this injury?

79.Dr. Anita Desai owns a policy that, while she is disabled, pays the office rent, staff wages, and utility bills. It does not replace her personal salary. What product is this?

80.Ada and Jules want a policy that, after a long waiting period, provides money to buy out the partner who becomes totally disabled. Which product fits?

81.A company buys and owns a disability policy on its lead engineer, pays the premium, and will receive the benefit if that engineer is disabled. The aim is to offset the business loss. What is this?

82.A client says Social Security disability uses a strict test of ability to work and asks which private definition is closer to that idea. Which comparison is right?

83.Faye Lind's individual disability policy reduces its monthly benefit by the Social Security disability benefit she actually receives. What is that reduction called?

84.Accident and health rates are built mainly from how often insured people are likely to become ill or injured. What is that likelihood called?

85.While taking an application, a producer sees the applicant struggle to walk, but the form says there is no limit on mobility. What should the producer do?

86.Statements on an accident and health application are representations. What follows from that?

87.An applicant for disability insurance denies a recent back injury. The insurer would have declined the application if it had known. A claim arises eight months later, inside the contestable period. What may the insurer do?

88.An applicant knows a surgery is already scheduled and deliberately leaves it off the disability application. What is that withholding of a material fact called?

89.For an individual accident and health policy, who has an insurable interest in a person's health?

90.To make Hector Salas replace his health plan, a producer falsely says the old plan excludes hospital care. The old plan does cover hospital care. What unfair practice is this?

91.A producer offers to hand back half of the first-year commission if a buyer purchases a disability policy today. In most states, what is that offer?

92.A producer calls a hospital indemnity policy full major medical and says it will pay the hospital bill. The policy pays only $150 a day. What did the producer do?

93.A producer places a client's health premium in the producer's personal bank account and plans to send it to the insurer later. What duty is breached?

94.Evan Poirier is a self-employed carpenter, age 34, who already has major medical coverage. He wants income if a back injury keeps him off the job for months. Which recommendation fits?

95.Each year a producer replaces Oscar Ng's disability policy with a nearly identical policy. Oscar's benefits do not improve, contestable periods start over, and the producer earns a new commission. The old benefits are not misstated. What is the problem?

96.A child is covered by both parents' employer health plans. The mother's birthday is in April and the father's is in September. No court order says otherwise. Which plan is commonly primary?

97.A covered surgery costs $8,000. The primary group plan pays $6,000. The secondary group plan's normal benefit would be $5,000. Coordination of benefits applies. What is the most the secondary plan should pay?

98.A health plan pays a member's bills for injuries caused by another driver, then seeks repayment from that driver's liability insurer. What is the health plan's right called?

99.An HMO pays a clinic a set amount each month for every member assigned there, whether or not the member comes in. What is that payment method?

100.In an HMO, the primary care doctor coordinates care and referrals to specialists. What is that role often called?

101.In one HMO model, the physicians are employees who treat members at the plan's own facilities. Which model is that?

102.A plan covers nonemergency care only from network providers, pays nothing for routine out-of-network care, and does not require a primary-doctor referral. Emergencies are still covered. What plan is this?

103.An enrollee in an ACA-compliant major medical plan goes to the nearest emergency room for a true emergency. The hospital is outside the plan network. Which statement is correct?

104.A plan requires a call for approval before a nonemergency hospital admission. The member does not call, and the contract then reduces what the plan pays. What requirement was missed?

105.Jordan Ames receives a new individual health policy, reviews it, and returns it within the free-look period printed in the policy. No claim has occurred. What is the usual result?

106.A doctor agrees to accept a health plan's allowed amount for a covered service. The member may still owe the deductible and coinsurance, but not the charge above the allowed amount. What kind of provider is this?

107.For a routine nonemergency office visit, a member sees a nonparticipating doctor. The plan pays its out-of-network share of the allowed amount. The doctor bills the member for the rest of the full charge. What is that extra bill called?

108.Ned Calhoun changes from tower climbing to office scheduling, a less hazardous occupation. His disability policy includes the change-of-occupation provision. What can he commonly obtain?