SCLAHIP - South Carolina Life Accident and Health Insurance Producer Exam

Question 1: An insured exhausts the first-dollar benefits of a basic plan and must satisfy a further dollar amount before the supplemental layer of coverage begins paying on the same claim. Which of the following names the amount she must satisfy in that gap?

A carryover deductible

A flat deductible

A corridor deductible

A stop-loss limit

Question 2: An employer offers both short term and long term disability plans and wants no gap in income for a worker who stays disabled. The short term plan pays for six months. How should the long term plan's elimination period be set?

To equal the short term benefit period

At thirty days regardless of other coverage

At two years to control cost

There is no elimination period

Question 3: A health maintenance organization pays a contracted medical group a fixed monthly amount for each enrolled member assigned to that group, whether or not those members seek any treatment during the month. Which term names this method of paying the provider?

Co-payment

Coinsurance

Usual, customary and reasonable payment

Capitation

Question 4: An underwriter reviewing an application for individual disability income coverage caps the monthly benefit at roughly sixty-five to seventy percent of the applicant's after-tax earned income rather than replacing the full paycheck. Which reason best explains that industry practice?

Full replacement removes the incentive to work

It equalizes premiums across all occupations

It guarantees a shorter elimination period

Insurers cannot verify income above that level

Question 5: An insured pays monthly premiums and is hospitalized eight days after a missed due date, while the policy is still within its grace period. Which statement correctly describes both the length of that grace period and the insurer's obligation for the loss?

Ten days, but the claim is denied

Thirty-one days, and the claim is denied

Ten days, and the claim is payable

Seven days, and coverage already lapsed

Question 6: Subscribers to one managed care plan use a primary care physician for prepaid in-network care with no claim forms, yet may also go outside the network and be reimbursed a percentage after filing a claim. Which plan works this way?

A point of service plan

A closed panel health maintenance organization

A comprehensive major medical policy

A flexible spending arrangement

Question 7: A surgeon bills a fee well above what other surgeons in the same area charge for the identical procedure. The insured's policy pays only the prevailing amount for that area and she is billed the difference. Which standard did the company apply?

A benefit schedule

A per cause maximum

A coinsurance percentage

Usual, reasonable and customary charges

Question 8: An employer offers a network plan that requires no referral to see a participating specialist, yet pays nothing at all when a member uses a provider outside the network except in a true emergency. Which plan design does this best fit?

A preferred provider organization

A point of service plan

An exclusive provider organization

A traditional indemnity plan

Question 9: A single policy provides broad medical expense protection with no underlying basic contract beneath it, pays benefits after the insured satisfies one deductible, and shares remaining covered costs with the insured until a stop-loss limit is reached. Which plan is described?

Supplemental major medical

Comprehensive major medical

Basic hospital expense coverage

A point of service plan

Question 10: A group medical plan is set up so that the employees pay part of the cost of their own coverage. Which minimum level of participation among eligible employees must the insurer normally see before it will issue such a plan?

One hundred percent of those eligible

Fifty percent of those eligible

Seventy-five percent of those eligible

Twenty-five percent of those eligible

Question 11: After an insured has paid the full annual deductible under a major medical policy, the plan and the insured continue to divide each covered charge on a stated percentage basis. Which feature of the policy produces that continuing division of cost?

The deductible

The stop-loss limit

The corridor deductible

Coinsurance

Question 12: A producer explains two waiting rules in a client's new health policy: one bars benefits for sickness that begins soon after the policy date, and the other delays payment until the insured has been disabled for a set number of days. Which pairing names them in order?

Elimination period, then probationary period

Probationary period, then elimination period

Corridor deductible, then probationary period

Probationary period, then coinsurance requirement

Question 13: A carpenter loses his dominant hand in a table saw accident and asks whether his disability income policy must pay benefits automatically without proof that he cannot work. Under the usual presumptive disability wording, how should the producer answer?

Yes, because the hand is dominant

Yes, any limb loss is presumptive

No, presumptive status requires two limbs

Yes, if he stops working entirely

Question 14: An employee collected disability benefits for a herniated disc, returned to work in February, and the same condition disabled him again six weeks later. His insurer resumed payments immediately without another waiting stretch. Which policy provision explains that treatment of the second claim?

Recurrent disability

Presumptive disability

Residual disability

Partial disability

Question 15: A worker chooses a medical plan whose monthly premium is unusually low, but she must pay a large amount out of her own pocket each year before the plan begins covering her care. Which type of plan has she chosen?

A basic hospital expense plan

A point of service plan

A prepaid health maintenance organization

A high deductible health plan

Question 16: An insured exercises an option date under her future increase option rider and buys an additional layer of coverage. She expects the new layer to be priced at the age she was when the policy was first issued. Which of the following is correct?

The new coverage uses her original age

She must furnish evidence of insurability

The new coverage uses her attained age

The rider sets no limit per option

Question 17: Two partners in an engineering firm sign an agreement setting a price for each partner's interest if one becomes permanently disabled, and they fund the promise with insurance that supplies the purchase money. Which business insurance arrangement have these two partners created?

Business overhead expense coverage

A disability buy-sell agreement

A key person disability plan

A group short term disability plan

Question 18: An insured pays a fixed twenty-five dollars at the front desk for each office visit, regardless of what the physician charges for that visit, and the policy handles the balance of the covered charge. Which cost-sharing feature is this?

A copayment

Coinsurance

A calendar year deductible

A per cause deductible

Question 19: An employee is laid off and elects to continue the employer's group health coverage for himself. Assuming premiums are paid and no disqualifying event occurs, what is the maximum period the continuation may last following that particular qualifying event?

Twelve months

Twenty-nine months

Thirty-six months

Eighteen months

Question 20: An employer pairs a plan carrying a relatively high deductible with an account it funds entirely with pretax employer dollars, from which employees may be repaid for deductibles, coinsurance and co-payments. Which arrangement has the employer established for its workers?

A health reimbursement account

A flexible spending arrangement

A health savings account

A medical savings account

SCLAHIP South Carolina Life Accident and Health Insurance Producer Exam - Set 4 - Part 1

Question 1: An insured exhausts the first-dollar benefits of a basic plan and must satisfy a further dollar amount before the supplemental layer of coverage begins paying on the same claim. Which of the following names the amount she must satisfy in that gap?

Question 2: An employer offers both short term and long term disability plans and wants no gap in income for a worker who stays disabled. The short term plan pays for six months. How should the long term plan's elimination period be set?

Question 3: A health maintenance organization pays a contracted medical group a fixed monthly amount for each enrolled member assigned to that group, whether or not those members seek any treatment during the month. Which term names this method of paying the provider?

Question 4: An underwriter reviewing an application for individual disability income coverage caps the monthly benefit at roughly sixty-five to seventy percent of the applicant's after-tax earned income rather than replacing the full paycheck. Which reason best explains that industry practice?

Question 5: An insured pays monthly premiums and is hospitalized eight days after a missed due date, while the policy is still within its grace period. Which statement correctly describes both the length of that grace period and the insurer's obligation for the loss?

Question 6: Subscribers to one managed care plan use a primary care physician for prepaid in-network care with no claim forms, yet may also go outside the network and be reimbursed a percentage after filing a claim. Which plan works this way?

Question 7: A surgeon bills a fee well above what other surgeons in the same area charge for the identical procedure. The insured's policy pays only the prevailing amount for that area and she is billed the difference. Which standard did the company apply?

Question 8: An employer offers a network plan that requires no referral to see a participating specialist, yet pays nothing at all when a member uses a provider outside the network except in a true emergency. Which plan design does this best fit?

Question 9: A single policy provides broad medical expense protection with no underlying basic contract beneath it, pays benefits after the insured satisfies one deductible, and shares remaining covered costs with the insured until a stop-loss limit is reached. Which plan is described?

Question 10: A group medical plan is set up so that the employees pay part of the cost of their own coverage. Which minimum level of participation among eligible employees must the insurer normally see before it will issue such a plan?

Question 11: After an insured has paid the full annual deductible under a major medical policy, the plan and the insured continue to divide each covered charge on a stated percentage basis. Which feature of the policy produces that continuing division of cost?

Question 12: A producer explains two waiting rules in a client's new health policy: one bars benefits for sickness that begins soon after the policy date, and the other delays payment until the insured has been disabled for a set number of days. Which pairing names them in order?

Question 13: A carpenter loses his dominant hand in a table saw accident and asks whether his disability income policy must pay benefits automatically without proof that he cannot work. Under the usual presumptive disability wording, how should the producer answer?

Question 15: A worker chooses a medical plan whose monthly premium is unusually low, but she must pay a large amount out of her own pocket each year before the plan begins covering her care. Which type of plan has she chosen?

Question 16: An insured exercises an option date under her future increase option rider and buys an additional layer of coverage. She expects the new layer to be priced at the age she was when the policy was first issued. Which of the following is correct?

Question 17: Two partners in an engineering firm sign an agreement setting a price for each partner's interest if one becomes permanently disabled, and they fund the promise with insurance that supplies the purchase money. Which business insurance arrangement have these two partners created?

Question 18: An insured pays a fixed twenty-five dollars at the front desk for each office visit, regardless of what the physician charges for that visit, and the policy handles the balance of the covered charge. Which cost-sharing feature is this?

Question 19: An employee is laid off and elects to continue the employer's group health coverage for himself. Assuming premiums are paid and no disqualifying event occurs, what is the maximum period the continuation may last following that particular qualifying event?

Question 20: An employer pairs a plan carrying a relatively high deductible with an account it funds entirely with pretax employer dollars, from which employees may be repaid for deductibles, coinsurance and co-payments. Which arrangement has the employer established for its workers?

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