NMLAHIP - New Mexico Life Accident and Health Insurance Producer

Question 1: A long-term care applicant names a trusted relative on her application so that, if she ever forgets to pay a premium because of confusion or memory loss, the insurer will notify that relative before the policy is allowed to lapse for nonpayment. What consumer protection does this naming provide?

An automatic beneficiary change

A waiver of premium guarantee

A designated third party for lapse notice

A power of attorney appointment

Question 2: An insured buys a policy that pays a benefit only if she is diagnosed with one of a short list of named serious illnesses, and the policy pays nothing for injuries or other illnesses that are not on that specific list. What type of limited policy is this?

A dread disease policy

A comprehensive major medical policy

A hospital indemnity policy

An accident-only policy

Question 3: An employee sets aside a portion of each paycheck into a salary-reduction account to pay anticipated medical expenses during the plan year, but at year end a meaningful balance remains unspent, and under the plan's general rule that balance is forfeited back to the employer. Which account features this rule?

A health savings account

A health reimbursement arrangement

A flexible spending account

A major medical deductible

Question 4: After an insured satisfies the annual deductible on a major medical policy, the plan pays a stated share of each additional covered expense, such as paying most of the remaining bill while the insured pays the smaller remaining share, until a limit is reached. Which feature is at work?

The deductible provision

The stop-loss limit

The coordination of benefits clause

The coinsurance provision

Question 5: A member of an HMO wants to see a dermatologist for a persistent skin condition but has not first obtained authorization from her primary care physician, so the plan denies payment for the visit entirely. Which characteristic of HMO plans does this denial illustrate?

Referral required for specialists

Guaranteed issue of coverage

Coordination of benefits

Portability of prior coverage

Question 6: An employee changes jobs and asks whether the balance in her tax-advantaged medical savings account stays with her former employer's plan or travels with her to the new job, since the funds accumulated while she was covered under the qualifying plan at her old job. What is the correct answer?

The balance reverts to the former employer

The balance is forfeited entirely

The account and balance follow her

The insurer keeps the balance

Question 7: An elderly man needs ongoing help with bathing, dressing, and eating because of a chronic condition, but he has no skilled nursing need and requires no rehabilitation services. Which of the following best describes how original Medicare treats this type of extended custodial care?

Medicare Part A pays indefinitely

Medicare Part B pays in full

Medicare covers it after a waiting period

Medicare generally excludes it

Question 8: An underwriter evaluating a proposed group health case reviews the average age of employees, the industry and occupational hazards involved, employee turnover, the size of the group, and the group's past claims experience rather than reviewing the health history of each worker. Which underwriting approach does this reflect?

Group underwriting based on group traits

Individual medical underwriting

Guaranteed issue with no review

Substandard rating of each applicant

Question 9: A consumer already enrolled in a private Medicare Advantage plan asks her agent whether she may also purchase a standardized Medicare Supplement policy to help with any remaining cost sharing under that private plan. How should the agent respond regarding this combination?

It is required for Medicare Advantage members

It automatically replaces her Medicare Advantage plan

It generally cannot be sold to her

It doubles her Medicare Advantage benefits

Question 10: An insured pays a modest premium for a policy that helps cover the cost of periodic eye examinations along with a portion of the cost of eyeglasses or contact lenses when needed. What type of specialized coverage does this policy provide?

Dental insurance

Cancer insurance

Long-term care insurance

Vision insurance

Question 11: A claimant is covered under two separate group health plans for the same medical expense, and the plans must decide which one pays benefits first and which one pays afterward to prevent the claimant from collecting more than the actual cost of care. What provision governs this determination?

Coordination of benefits

The subrogation clause

The entire contract clause

The insuring clause

Question 12: A member enrolled in a preferred provider organization schedules an appointment directly with an in-network orthopedic specialist without first visiting any other physician for approval, and the plan pays the claim at the in-network benefit level without objection. Which feature of PPO plans does this reflect?

A capitation payment arrangement

No gatekeeper referral requirement

A defined narrow service area

A qualifying event provision

Question 13: A newly eligible Medicare beneficiary enrolls in Part B for the first time, and for six months afterward she can buy any Medicare Supplement policy sold in her area without being turned down or charged more because of her health conditions. What is this six-month window called?

The initial enrollment period

The general enrollment period

The Medigap open enrollment period

The annual election period

Question 14: A federal portability law limits how far back a group health plan may look when identifying a condition as preexisting, and it also limits how long a plan may exclude benefits for that condition once identified, subject to reduction for the enrollee's prior creditable coverage. What concept does this describe?

A guaranteed renewability requirement

A coordination of benefits rule

An open enrollment mandate

Preexisting condition exclusion limits

Question 15: An insured is hospitalized for several days, and his supplemental policy pays him a fixed dollar amount for each day of that confinement, regardless of what the actual hospital bill turns out to be or what his other health insurance already paid. What type of policy pays benefits this way?

Hospital indemnity insurance

Major medical insurance

Dental insurance

Long-term care insurance

Question 16: A government health program for low-income individuals is funded through a combination of federal dollars and matching contributions from each jurisdiction that administers its own version of the program within broad federal guidelines. Which program does this joint funding and administration structure describe?

Medicare

Medicaid

Social Security disability benefits

A private group health plan

Question 17: A federal benefits law requires the person or entity named to run a covered employee benefit plan to provide participants with a summary plan description explaining their rights and to handle claims and reporting duties according to the law's minimum standards. Which role does this describe?

The plan fiduciary's beneficiary

The insurer's claims examiner

The plan administrator

The qualified beneficiary

Question 18: A newly hired employee enrolls in the company group health plan and receives a short booklet describing the benefits, exclusions, and claim procedures that apply to her coverage, rather than the lengthy contract the employer signed. Which document was the employee given?

The master policy

A binder

A conversion contract

Certificate of insurance

Question 19: A working daughter drops her elderly mother off each morning at a community center that provides supervision, social activities, and some health monitoring during the day, then picks her up again in the evening after work. Which level of long-term care does this daytime community program represent?

Adult day care

Respite care

Custodial care at home

Skilled nursing facility care

Question 20: A policy reimburses the cost of a physician's non-surgical office visits and home visits made while an insured is recovering from an illness, but the benefit amount is limited and the policy contains no deductible. Which type of coverage best fits this description?

Basic surgical expense insurance

Basic medical expense insurance

Basic hospital expense insurance