SDLAHP - South Dakota Life Accident and Health Producer

Question 1: Under an employer's group health plan, each enrolled worker pays a share of the monthly premium through payroll deduction, and the insurer requires that a minimum percentage of eligible workers actually enroll. Which type of plan does this arrangement describe?

a noncontributory group health plan

a fully insured association plan

a contributory group health plan

a self-funded employer plan

Question 2: An employer adds a separate benefit to its group offerings that pays scheduled amounts toward routine cleanings, fillings, and other procedures performed by a licensed dentist, often with a waiting period before major work is covered. Which type of coverage is being described?

dental insurance

vision insurance

hospital indemnity insurance

accident only insurance

Question 3: An insurer reviewing a long term care claim checks whether the claimant needs hands on help with a required number of activities such as bathing, dressing, and eating, or instead suffers from a severe cognitive impairment. Which concept governs whether benefits begin under most long term care policies?

the elimination period

the free look period

the benefit eligibility trigger

the guaranteed renewable clause

Question 4: One account is owned by the individual, carries its full balance forward every year, and requires enrollment in a qualifying high deductible health plan, while another account is funded by employee salary reduction, is owned within the employer's plan, and forfeits unspent amounts at year end. Which statement distinguishes them?

only the flexible spending account carries forward

both accounts require a deductible plan

neither account allows employee contributions

only the health savings account carries forward

Question 5: A member enrolls in a plan that requires choosing a primary care physician and obtaining referrals for the lowest-cost, in-network benefit level, yet the plan also allows the member to seek care outside the network at a higher deductible and coinsurance. Which plan type is this?

a point of service plan

an exclusive provider organization

a health maintenance organization

a health savings account

Question 6: An insurer combines basic hospital, surgical, and medical benefits together with catastrophic major medical protection into a single contract, applying one deductible and one coinsurance percentage across the whole range of covered expenses rather than layering a separate plan on top of another. Which arrangement does this describe?

supplementary major medical coverage

basic hospital expense coverage

comprehensive major medical coverage

a health reimbursement arrangement

Question 7: A newly hired employee is scheduled to start group health coverage on the first of the month but calls in sick and misses her first day entirely due to illness. Which provision most directly determines whether her coverage actually takes effect on that scheduled date?

the coordination of benefits clause

the guaranteed renewable provision

the pre-existing condition exclusion

the actively at work requirement

Question 8: An employee funds a personal account through payroll contributions while enrolled in a qualifying high deductible health plan, and when that employee later changes employers, the entire account balance moves along with the employee rather than reverting to the former employer. Which feature does this describe?

individual ownership and portability

employer ownership of the account

the forfeiture rule of accounts

the network structure of a plan

Question 9: An employer sets up a notional account for each employee and funds it entirely with employer dollars to reimburse eligible medical expenses, decides which expenses qualify and whether any unused balance carries forward, and the account does not travel with the employee after employment ends. Which arrangement does this describe?

a health savings account

a flexible spending account

a health reimbursement arrangement

an exclusive provider organization

Question 10: A patient recently discharged from the hospital now requires daily wound care and careful medication management performed under a physician's direction by a licensed nurse inside a specialized nursing facility setting. Which level of long term care does this situation best describe?

custodial care

adult day care

respite care

skilled nursing care

Question 11: An employee who had continuous group health coverage with a prior employer, without a significant break, enrolls in a new group health plan, and a federal law limits how long the plan may exclude coverage for a preexisting condition by crediting the employee's prior coverage. Which law does this describe?

the Health Insurance Portability and Accountability Act

the Consolidated Omnibus Budget Reconciliation Act

the Employee Retirement Income Security Act

the Affordable Care Act

Question 12: A supplemental policy pays a substantial lump sum or scheduled series of benefits only if the insured is diagnosed with one specifically named illness, and it is marketed as additional protection rather than as a replacement for comprehensive major medical coverage. Which type of policy is described?

a comprehensive major medical policy

a cancer or dread disease policy

a hospital indemnity policy

a basic accident only policy

Question 13: An individual who exercises discretionary authority over the management of an employer group health plan or its assets is legally required to act solely in participants' and beneficiaries' interest and with the care a prudent person would use in a similar position. Which concept does this obligation describe?

capitation

guaranteed issue

fiduciary duty under federal plan law

coordination of benefits

Question 14: A nursing home resident has exhausted her limited assets paying privately for custodial care that Medicare does not cover, and she now needs another source to pay for her continued stay in the facility. Which program is most likely to pay for this ongoing custodial nursing home care?

Medicare Part A

a Medigap policy

a disability income policy

Medicaid

Question 15: Before pricing a new group health case, an insurer's underwriter reviews the employer's industry, average age of the workforce, geographic location, and historical claims experience rather than reviewing any single applicant's medical records. Which underwriting approach does this best illustrate?

risk assessment at the group level

individual medical underwriting

simplified issue underwriting

guaranteed issue for one applicant

Question 16: An employee leaves her job and loses eligibility for the employer's group health plan, but she wants to keep some coverage on her own without answering any new health questions. Which policy feature allows her to obtain an individual policy under these circumstances?

the COBRA continuation right

the conversion privilege

the coordination of benefits rule

the reinstatement provision

Question 17: A retiree visits her primary care physician for a routine outpatient checkup and later needs a piece of durable medical equipment prescribed by that same doctor. Which part of Medicare is primarily designed to pay for physician visits and this kind of outpatient equipment?

Medicare Part A

Medicare Part C

Medicare Part B

a stand alone dental plan

Question 18: A long term care claimant needs regular help with bathing, dressing, and moving from bed to chair, but she requires no skilled nursing procedures and is not recovering from any recent medical treatment. Which level of care does her situation best describe?

skilled nursing care

intermediate nursing care

acute hospital care

custodial care

Question 19: A worker's hours are reduced below the level required for group health eligibility, causing her to lose coverage under her employer's plan even though she remains employed. Which federal law gives her the right to temporarily continue the same group coverage at her own cost?

the federal COBRA continuation law