Insurance Licensing Updated InsNV_Health02 Exam Questions and Answers by cristian

A preferred provider organization, or PPO, contracts with a network of preferred providers who agree to provide services under negotiated payment arrangements. Members generally receive the highest level of benefit and lowest out-of-pocket cost when they use participating providers. Many PPOs also permit use of nonnetwork providers, but the member normally pays more through a higher deductible, higher coinsurance, balance billing exposure, or reduced reimbursement.

A PPO differs from a traditional HMO because it commonly provides more flexibility in choosing providers and may not require a primary-care referral for specialist care. However, the tradeoff may be higher premiums, higher cost sharing, and more complex reimbursement rules. A PPO is still managed care; it may use prior authorization, utilization review, formularies, and network rules.

A producer should explain provider-network access, emergency-care rules, deductible and coinsurance amounts, out-of-network payment limitations, and whether a provider is actually participating at the time of enrollment. The phrase “you can see any doctor” can be misleading if nonnetwork care is covered at a lower level or exposes the insured to significant unpaid charges.

References/topics from the Study Guide: PPO; Managed Care; Provider Networks; In-Network and Out-of-Network Benefits; Cost Sharing.

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Specified disease insurance provides limited benefits for a condition or group of conditions specifically named in the policy, such as cancer, heart disease, or stroke. The benefits may be paid as reimbursement for certain covered expenses, as fixed cash amounts for treatment events, or through a schedule of benefits. The scope of coverage is controlled by the policy and is substantially narrower than comprehensive major medical insurance.

A producer must not represent specified disease coverage as complete health insurance. It may help with deductibles, travel, household costs, experimental-treatment expenses not covered elsewhere, or income disruption, but it is not a substitute for comprehensive coverage that addresses a broad range of illnesses and injuries. The client should understand covered conditions, waiting periods, recurrence provisions, preexisting-condition limitations where permitted, benefit schedules, exclusions, and whether the policy pays in addition to other coverage.

Major medical insurance is intended to cover a broad spectrum of medically necessary expenses. Credit disability insurance is connected to repayment of a debt if the debtor becomes disabled. Group term life insurance pays a death benefit and does not provide medical-expense coverage. The examination point is to identify the limited, condition-specific purpose of specified disease insurance.

References/topics from the Study Guide: Specified Disease Insurance; Cancer Insurance; Critical Illness Coverage; Limited-Benefit Health Insurance; Major Medical.

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An HSA is generally available to an eligible individual who is covered by a qualified high-deductible health plan, commonly called an HDHP, and who meets the other federal eligibility requirements. The account is owned by the individual, not the employer or insurer. Contributions may be made by the individual, an employer, or another person, subject to annual contribution limits. Qualified distributions used for eligible medical expenses are generally tax advantaged under federal rules.

Eligibility is not based solely on having a high deductible. The health plan must meet the federal HDHP requirements for the applicable year. In addition, an individual generally cannot be enrolled in Medicare, cannot be claimed as another person’s tax dependent, and cannot have disqualifying other health coverage. Because federal limits and requirements can change, the producer should not provide individualized tax advice and should refer the consumer to current IRS guidance or a qualified tax professional.

An HSA differs from a flexible spending arrangement because unused HSA funds generally remain with the account owner and may carry forward. It also differs from health insurance itself; the HSA is a tax-advantaged account used alongside an eligible health plan.

References/topics from the Study Guide: Health Savings Accounts; High-Deductible Health Plans; Consumer-Directed Health Plans; Tax-Advantaged Medical Accounts.

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Medicaid is a means-tested public medical assistance program for eligible low-income individuals and families. Eligibility may include persons who are blind, disabled, aged, pregnant, children, or otherwise within an eligible category under federal and state rules. Therefore, choice A is correct. There is no universal minimum age of 55 for Medicaid eligibility; eligibility is based principally on financial and categorical requirements. Medicaid is also not simply a program supplemented by Medicare at age 62. Medicare eligibility is generally associated with age 65 or qualifying disability or disease status, while Medicaid may assist certain eligible persons with limited income and resources, including some Medicare beneficiaries. Medicaid is jointly financed by federal and state governments but is administered by the states within federal standards. In Nevada, the state administers the program through its designated health and human-services structure. Examination questions commonly test the distinction between Medicare as social insurance and Medicaid as needs-based medical assistance. Study Guide References/Topics: Social Insurance Programs; Medicaid; Federal-State Health Programs.

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