Insurance Licensing Updated InsNV_Health02 Exam Questions and Answers by ivar

The Affordable Care Act established Essential Health Benefits as the minimum categories of benefits that qualifying individual and small-group health plans must cover. These required benefit categories create a baseline of comprehensive coverage rather than allowing a major medical plan to omit fundamental types of care.

Essential Health Benefits include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance-use-disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services, chronic-disease management, and pediatric services, including oral and vision care.

Gold and Silver are metal-level plan categories. They describe the general actuarial value of a plan—the approximate division of covered health-care costs between the insurer and enrollees—not a separate legal list of mandatory minimum benefits. A Gold plan generally pays a larger share of covered costs than a Silver plan, but both must include the applicable Essential Health Benefits. “Silver Saver Value” and “Medicaid Buy-Back” are not the ACA’s required minimum-coverage terminology.

For examination purposes, distinguish the benefit package itself—Essential Health Benefits—from plan metal levels and from public programs such as Medicaid.

Study Guide references/topics: Affordable Care Act; individual health insurance; qualified health plans; Essential Health Benefits; HealthCare.gov coverage protections .

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A health plan’s waiting period generally may not exceed 90 calendar days for an individual who is otherwise eligible to enroll. A waiting period is the period that must pass before coverage becomes effective for an employee or dependent who has met the plan’s substantive eligibility conditions. The rule is intended to limit extended gaps in employer-sponsored health coverage for eligible individuals.

The 90-day limitation does not mean that every new employee must receive coverage immediately on the first day of work. An employer may use reasonable eligibility requirements, such as a bona fide job classification or an hours-of-service requirement, as long as the arrangement is structured and administered in compliance with applicable federal rules. The producer should not treat every orientation period or administrative condition as automatically permissible; plan documents and current legal guidance matter.

This issue is distinct from preexisting-condition exclusions. Modern health-insurance rules significantly restrict the use of preexisting-condition exclusions in major medical coverage. It is also distinct from an elimination period in disability insurance, which is a waiting period after a disability begins rather than a waiting period for plan eligibility.

References/topics from the Study Guide: Group Health Eligibility; Waiting Periods; Employer-Sponsored Coverage; Federal Health-Insurance Requirements; Nevada Group Health Rules.

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Long-term-care insurance commonly uses functional and cognitive triggers to determine benefit eligibility. A typical trigger is certification that the insured cannot perform at least two activities of daily living, or ADLs, without substantial assistance for the required period. Common ADLs include bathing, continence, dressing, eating, toileting, and transferring. Another common trigger is severe cognitive impairment requiring substantial supervision to protect the insured’s health and safety.

Long-term-care coverage is not based merely on reaching a certain age, unemployment, or a premium-payment issue. It is designed to help pay for qualifying long-term services when the insured needs ongoing assistance because of chronic illness, disability, or cognitive impairment. Covered services may include nursing-home care, assisted living, adult day care, home health care, hospice care, and respite care, depending on the policy.

The producer should explain the elimination period, daily or monthly benefit limit, benefit period, inflation-protection options, facility restrictions, and policy exclusions. An insured may need care for years, so a policy with a low daily benefit or short benefit period may not meet the client’s needs. Suitability requires evaluating likely care preferences, assets, family support, and affordability.

References/topics from the Study Guide: Long-Term Care Insurance; Activities of Daily Living; Cognitive Impairment; Benefit Triggers; Elimination Period.

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Reinstatement restores a lapsed life insurance policy to active status if the policyowner satisfies the policy’s requirements. Those requirements generally include applying for reinstatement within the permitted period, providing evidence of insurability satisfactory to the insurer, and paying overdue premiums plus interest. The exact reinstatement period and underwriting requirements are controlled by the policy and applicable law.

A new medical examination is not required in every case. The insurer may request medical information or an examination when needed to evaluate the applicant’s current insurability, but it is not an automatic universal requirement. The key examination principle is that evidence of insurability is required, not that a physical examination must always occur. Reinstatement is often preferable to purchasing a new policy because the existing policy may have more favorable premium rates, accumulated cash value, or a prior issue age. However, the policyowner must understand that contestability and certain exclusions may begin again with respect to the reinstatement.

A producer should explain the difference between reinstatement and renewal. Reinstatement restores a policy that lapsed; renewal continues or extends a policy under its existing terms. Neither should be assumed available without reviewing the contract.

References/topics from the Study Guide: Reinstatement Provision; Policy Lapse; Evidence of Insurability; Premium Payment; NRS 688A.130.

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