NJ Health Insurance Exam 2025

Total disability definition can - -vary among policies and companies Permanent partial disability would be covered by - -residual disability An agent discussing disability income coverage with an individual who has recently finished college and started with an entry-level job. What rider should the agent recommend for the client? - -Guaranteed insurability rider Allows you to purchase additional disability income insurance in the future without having to prove insurability Example of a presumptive disability - -Nancy was completely blinded and will not recover her sight Presumptive (catastrophic) disability - --often written with a disability policy -disability of the insured will be presumed to be Total & Permanent upon loss of sight, loss of the use of 2+ limbs, loss of hearing, loss of speech How do Disability Income policies differ? - --Whether or not coverage is provided in addition to Worker's Comp -The length of the elimination period -How "Total Disability" is defined An individual who has had a heart murmur since birth is likely to be issued a policy that includes - -An impairment rider Impairment rider (exclusion rider) - -Takes away coverage for a specified medical condition (diabetes or epilepsy) Before Mr. Jones was disabled, he was a full-time engineer earning about $70,000 annually. Now, two years later he is able to work part-time, earning about $25,000 annually. It is Likely that Mr. Jones is classified as - -partially disabled What is the purpose of the elimination period? - -It specifies the number of days between which disability benefits will be paid NJ Health NJ Health Under NJ minimum standards for individual health insurance policies, a probationary period for "sickness" may not exceed - -30 days Recurrent disability - -recurs due to the same benefit or related cause of loss within 6 months of the back to work date, no elimination period upon recurrence Basic Hospital Plan covers - --daily hospital room & board -miscellaneous hospital services -Hospital outpatient services Basic Medical Surgical covers - --surgical expenses -anesthesia services -In hospital physician services Basic medical plan - --Minimal benefits -No deductible When a health insurance plan operates on a reimbursement basis, benefits are paid to - -the insured Physician's expenses for nonsurgical care rendered in the hospital and for visits to a physician's office would be covered under - -Major Medical Major Medical characteristics - -Broad coverage of "covered" or "eligible" expenses with: -few exclusions -high max limits -uses deductibles, coinsurance, and internal pay limits Another term for "stop loss limit" - -out of pocket limit Once an insured major medical policy reaches its stop loss limit, the insured will be required to pay how much of the additional covered expenses? - -0 What is the purpose of a deductible - -to prevent over-utilization The concept the insurer and the insured share in the cost of medical expenses, with the insurer usually bearing the greater share? - -Coinsurance Major medical may include a type of deductible where the insured pays a new deductible for each different event that causes a medical expense to be incurred - -per cause deductible Is dental included in Major Medical? - -no Blue cross blue shield makes payments for medical expenses - -on a service basis directly to the providers NJ Health NJ Health When medical expense policies do not state specific dollar benefit amounts, but instead base payments upon the charges for like services in the same geographical are, the benefits are described as - -Usual, reasonable, and customary charges Managed care concepts involve - -precertification for a hospital stay Characteristic of a staff model HMO - -the health service charges a flat fee for medical care provided at its own clinic How do PPO pay network physicians - -Fee-for-service Common characteristics of an HMO - --emphasis on preventative care -network based benefits Mary smith is required to seek approval from her PCP before consulting with a specialist about her back pain. Mary is subject to - -precertification A point-of-service (pos) plan operates like a combination of - -HMO and PPO Consumer-driven health plans are characterized by - --choices given to the consumer as to how benefit dollars are used -pre-tax dollars for qualified medical expenses -arranged through an employment group Who sets up and funds an Health Reimbursement Account (HRA) - -the employer What is used to provide medical coverage under a Health Savings Account (HSA) - high-deductible health plan Which type of plan pays a lump sum benefit, but only upon diagnosis of a specified disease - -critical illness plan A 68 year old man had a heart attack on January 1st. Three months later he purchased an individual health insurance policy. On December 1st of that year he has another heart attack. Which type of policy would he have had to purchase for it to cover the December heart attack? - -Medicare supplement Can you duplicate Medicare benefits with Medicare Supplement coverage? - -NO Characteristics of Medicare Supplement Coverage - --outline of coverage provided at time of application -commissions paid to producers are regulated NJ Health NJ Health -standardized plans are available Medicare Supplement coverage can be solicited over the phone (T/F) - -False Under the NJ Temporary Disability Law, benefits are provided only if the injury or illness sustained by the covered worker is - -no occupational Worker's comp benefits are provided for injuries and illnesses that are - -occupational NJ Temporary Disability Law characteristics - --a 7 day waiting pe