PLAHI - Pennsylvania Life Accident and Health Insurance Exam

Question 1: A Pennsylvania employer sponsors a group health plan, and each covered worker receives a short document summarizing benefits while the employer keeps the full agreement with the insurer. Which of the following correctly names the two documents involved?

Master contract and certificate of coverage

Certificate of authority and policy summary

Application and conditional receipt

Outline of coverage and buyer's guide

Question 2: An insurer in Philadelphia reviews four prospective groups and must decline any group that was formed for the sole purpose of buying insurance for its members. Which of the following principles explains why that restriction exists in group underwriting?

It ensures every member is individually underwritten

It satisfies the state fiduciary requirement

It keeps the employer from paying premium

It prevents adverse selection in the group

Question 3: A Pennsylvania employer asks its producer how many eligible employees must enroll under a plan where workers pay part of the premium, compared with a plan the employer funds entirely. Which of the following states both participation levels?

Fifty percent and seventy-five percent

One hundred percent and seventy-five percent

Seventy-five percent and one hundred percent

Twenty-five percent and fifty percent

Question 4: One Pennsylvania group is priced using the claims history of that specific employer, while a second group is priced by pooling many employers together and charging them a common rate. Which of the following correctly names these two methods?

Community rating and experience rating

Retrospective rating and prospective rating

Manual rating and judgment rating

Experience rating and community rating

Question 5: A new employee at a Reading distributor is hired full time but is on approved medical leave and has not yet reported for duty. The plan requires that she be actively at work. Which of the following describes her eligibility?

She is eligible on her hire date

She may enroll only during open enrollment

She becomes eligible once actively at work

She is permanently ineligible for the plan

Question 6: A Pennsylvania employer requires new hires to complete ninety days of service before they may join the group plan, and they then have a limited window to sign up without health questions. Which of the following names those two periods?

Probationary period and enrollment period

Elimination period and grace period

Free look period and open enrollment

Waiting period and contestable period

Question 7: A Pennsylvania employee declines group coverage when first eligible and asks to join eighteen months later, outside any annual window. Which of the following describes what the insurer may require of him that it would not require during open enrollment?

A full year of additional service

Written consent from the employer

Payment of all past premiums

Answers to medical questions

Question 8: A child in Bucks County is covered under both parents' group health plans, and the parents are married and living together in the same household. Which of the following determines which plan is primary for that child's claims?

The parent with the earlier birthday

The parent who is older in age

The plan with the larger annual maximum

The plan the child used most recently

Question 9: A Pennsylvania employer replaces its group health carrier while an employee is in the middle of a long course of treatment, and the employee worries about losing benefits mid-claim. Which of the following principles applies to that transition?

The claim is denied by both carriers

The employee must satisfy two deductibles

No loss and no gain in benefits

Coverage restarts after a new probationary period

Question 10: A Pennsylvania benefits administrator lists the various events that can end an employee's or a dependent's group health coverage under the plan. Which of the following combinations correctly describes events that terminate coverage for a dependent rather than for the employee?

Divorce and a child aging out

Layoff and reduction in hours

Employer nonpayment of premium

Voluntary resignation by the employee

Question 11: A Pennsylvania employer with thirty-two employees terminates a worker for ordinary performance reasons rather than for gross misconduct, and the worker wants to keep the group health coverage. Which of the following describes the continuation law that applies here?

Pennsylvania Mini-COBRA applies

No continuation right exists

Only a conversion policy is available

Federal COBRA applies to this employer

Question 12: A Pennsylvania worker loses group coverage when his hours are cut back, and at a different employer a covered spouse loses coverage through divorce. Which of the following states the maximum federal continuation period available in each situation?

Twelve months for both situations

Thirty-six months and eighteen months

Eighteen months and thirty-six months

Nine months and eighteen months

Question 13: A Pennsylvania qualified beneficiary elects federal continuation coverage after leaving her job, and she asks what she will pay compared with the group rate her employer was charged. Which of the following states the maximum she may be charged?

The employee share only

One hundred five percent of group rate

Two hundred percent of the group rate

One hundred two percent of group rate

Question 14: A Pennsylvania employee whose group health coverage is ending wants an individual converted policy without having to prove insurability. Which of the following states how long she must have been continuously insured and how quickly she must apply?

Three months insured; apply within thirty-one days

One year insured; apply within sixty days

Six months insured; apply within ten days

No prior period; apply within ninety days

Question 15: A Pennsylvania employer with eleven employees ends a worker's employment for reasons other than gross misconduct, and the worker asks about continuing the small group health coverage. Which of the following states the duration and maximum premium under Pennsylvania Mini-COBRA?

Eighteen months at one hundred two percent

Nine months at one hundred five percent

Thirty-six months at one hundred percent

Twelve months at one hundred ten percent

Question 16: A Pennsylvania producer explains to a client that a person may qualify for Medicare in more than one way. Which of the following combinations correctly describes the routes to eligibility besides simply reaching the qualifying age of sixty-five?

Any disability lasting three months

Pregnancy or low income

End-stage renal disease or long-term disability benefits

Military service or veteran status

Question 17: A Pennsylvania retiree in Erie asks which services Medicare Part A pays for after she satisfies the deductible for a given benefit period. Which of the following correctly lists the services covered under that part of the program?

Physician office visits and outpatient laboratory work

Routine dental care and eyeglasses

Outpatient prescription drugs purchased at retail

Inpatient hospital, skilled nursing, home health, hospice

Question 18: A Pennsylvania Medicare beneficiary is discharged from a hospital and is not readmitted or in a skilled nursing facility for a stretch of time, after which a new benefit period begins. Which of the following states that required interval?

Sixty consecutive days

Thirty consecutive days

Ninety consecutive days

One hundred consecutive days

Question 19: A Pennsylvania beneficiary enters a skilled nursing facility directly after a qualifying inpatient hospital stay, and Medicare pays the full cost for the first portion of her stay. Which of the following describes the coverage limits that apply?

Full payment for one hundred days

Full payment for all covered days

Twenty days in full, then daily copayment

No coverage without a prior surgery

Question 20: A Pennsylvania beneficiary with a terminal illness elects a Medicare benefit focused on pain relief, symptom management and family counseling rather than on curative treatment. Which of the following describes that benefit and where it may be provided?

Skilled nursing care, in a facility only

Hospice care, at home or a facility

Custodial care, in any chosen setting

Respite care, only in a hospital

PLAHI Pennsylvania Life Accident and Health Insurance Exam - Set 5 - Part 1