NLHI - Nevada Life and Health Insurance Exam

Question 21: An HMO member traveling far outside the plan's geographic service area suffers a genuine medical emergency and receives care from a non-network hospital. HMOs generally define coverage by a service area yet still address urgent situations. How are emergencies typically handled?

Never covered outside the service area

Covered only with prior authorization

Covered anywhere, any hour, when truly emergent

Covered only at network hospitals

Question 22: An examiner distinguishes an HMO from a traditional insurer by what each actually provides. A traditional insurer supplies only one function, while an HMO supplies two. Which statement best captures how an HMO differs from a traditional health insurer?

An HMO only reimburses billed charges

An HMO sells only indemnity coverage

An HMO never employs any providers

An HMO provides both care and financing

Question 23: A PPO member may use any provider but pays less when staying in the preferred network. The member weighs the added cost of leaving the network. Comparing the two benefit levels, how does a PPO typically structure in-network versus out-of-network reimbursement?

Higher benefits in-network, lower out-of-network

Identical benefits regardless of network

No benefits outside the network at all

Higher benefits out-of-network to encourage choice

Question 24: A student lists managed care models such as HMO, PPO, and POS, then asks which traditional arrangement is not considered managed care because it simply pays benefits without a provider network or care coordination. Which arrangement is that?

Health maintenance organization

Traditional indemnity insurance

Preferred provider organization

Point-of-service plan

Question 25: A dental plan lists categories of covered services. A teenager needs braces to correct the alignment of the teeth and jaw. The dentist recommends appliances to straighten the teeth. Under standard dental coverage categories, which category covers braces and similar alignment treatment?

Endodontics

Periodontics

Orthodontics

Prosthodontics

Question 26: A dental patient is diagnosed with a disease of the gums and the bone that supports the teeth, requiring specialized treatment. The infection reaches the bone beneath the teeth. Under standard dental plan categories, which category covers treatment of the gums and supporting structures?

Endodontics

Orthodontics

Oral surgery

Periodontics

Question 27: A dental plan enumerates service categories. A patient must have several teeth surgically extracted and a related jaw procedure performed. The work is surgical rather than routine. Under typical dental coverage categories, which category covers extractions and surgical procedures of the mouth and jaw?

Oral surgery

Restorative

Diagnostic

Prosthodontics

Question 28: Two dental plans differ in how they pay. One lists a fixed dollar allowance for each procedure, while the other pays a percentage of usual, customary and reasonable charges. The choice affects how much the plan pays. What are these two payment approaches respectively called?

Basic and major plans

Indemnity and reimbursement plans

Scheduled and nonscheduled plans

Open and closed panel plans

Question 29: Under the Affordable Care Act, non-grandfathered individual and small-group plans must cover a defined set of benefit categories, including hospitalization, maternity, and prescription drugs. Every qualifying plan must include this same core set. What are these mandated categories collectively called?

Coordinated care benefits

Essential health benefits

Guaranteed renewal benefits

Supplemental benefits

Question 30: A parent wants to keep an adult child on the family health plan. The rule ignores the child's other circumstances. Under the Affordable Care Act, plans offering dependent child coverage must allow children to remain on a parent's plan up to what age?

Age nineteen

Age twenty-one

Age twenty-three

Age twenty-six

Question 31: Under the Affordable Care Act, certain in-network preventive services, such as immunizations and recommended screenings, must be provided to members in a particular cost-sharing manner. The requirement removes cost as a barrier. How must non-grandfathered plans cover these preventive services?

With no cost sharing to the member

Only after the deductible is met

At fifty percent coinsurance

With a fixed copay each visit

Question 32: The Affordable Care Act created individuals to help consumers understand and enroll in exchange coverage. A producer notes these helpers have an important limitation compared with licensed agents. The limit separates them from licensed agents. What may an exchange navigator not do?

Explain available plan options

Help a consumer complete enrollment

Recommend or sell a specific plan

Provide unbiased coverage information

Question 33: Under the Affordable Care Act's employer shared-responsibility rule, an employer of a certain size must offer affordable, adequate coverage to full-time employees or face a potential penalty. At how many full-time-equivalent employees does this employer mandate generally apply?

Twenty or more full-time-equivalent employees

One hundred or more employees

Two or more employees

Fifty or more full-time-equivalent employees

Question 34: An applicant with a chronic illness fears being denied major medical coverage or having the condition excluded. The applicant fears a denial over health history. Under the Affordable Care Act, how are preexisting conditions treated in non-grandfathered major medical plans?

They may be excluded for twelve months

Cannot be excluded or denied coverage

Let the insurer decline the applicant

They permit a permanent rider exclusion

Question 35: A group health insurer sets premiums for a large employer based on that specific group's own claims history, while it prices coverage for small groups using the pooled experience of many groups in an area. What are these two rating methods called?

Experience rating and community rating

Manual rating and retrospective rating

Scheduled rating and judgment rating

Flat rating and loss rating

Question 36: State and federal rules often treat small employers differently from large ones for group health purposes. Under the commonly used federal definition applied by the Affordable Care Act, a small employer group generally consists of how many employees?

Up to five employees

Up to two hundred employees

Up to fifty employees

Exactly one hundred employees

Question 37: A worker leaves a job and wants to continue the employer's group health coverage under federal COBRA. COBRA applies only to employers of a certain minimum size. Federal COBRA generally applies to employers that had at least how many employees?

Two employees

Fifty employees

One hundred employees

Twenty employees

Question 38: After a qualifying event, a former employee receives a COBRA election notice and must decide whether to continue group health coverage. Under federal COBRA, how long does a qualified beneficiary have to elect continuation after the notice or coverage loss?

Sixty days to elect

Fourteen days to elect

Ninety days to elect

Thirty days to elect

Question 39: Under HIPAA's older creditable-coverage rules, prior health coverage could reduce a new plan's preexisting-condition waiting period, but only if there was no lengthy gap between coverages. A break in coverage longer than a set number of days erased that credit. How long was that significant break?

Thirty days

Sixty-three days

Ninety days

One hundred eighty days

Question 40: A producer explains who qualifies for Medicare. Besides reaching a certain age, some younger people also qualify through disability or a specific kidney condition. The producer maps each route to coverage. Which combination correctly describes common paths to Medicare eligibility?

Age sixty-two and retirement only

Low income and asset limits only

Age sixty-five, disability, or end-stage renal disease

Military service alone

NLHI Nevada Life and Health Insurance Exam - Set 4 - Part 2