Tennessee Health: Laws and Rules Review

Question 1

A health or disability policy is incontestable after it has been in force for a period of _____ years. Only _____ _____ in the application may be used to void the policy or deny any claim at this point.

Answer 1

2 years

fraudulent misstatements

Question 2

If an application for reinstatement and a premium payment have been submitted and the insurer does not notify the owner with additional requirements, the policy will be automatically reinstated after _____ days.

Answer 2

45 days

Question 3

Written proof for any loss must be given to the insurance company within _____ days.

Answer 3

90 days

Question 4

No legal action can be initiated within _____ days after proof of loss has been submitted to the insurance company. In addition, no legal action can be initiated after _____ years from the initial time written proof of loss has been provided.

Answer 4

60 days

3 years

Question 5

Health insurance policies must provide a minimum free-look period of _____ days upon policy delivery. This allows the policyowner time to decide whether or not to keep it. If the policyowner decides not to keep the policy within the _____ days allowed, a full refund will be given.

Answer 5

10 days

(Also known as the Right to Examine)

Question 6

A person who is eligible for Medicare has a free-look period of _____ days

Answer 6

30 days

Question 7

Group policies must include a _____ _____ which allows an employee whose employment terminates to convert group coverage to an individual plan without proof of insurability within _____ days.

Answer 7

conversion privilege

31 days

Question 8

Employees who have been covered under a group health plan for at least _____ months before their termination to be eligible to continue their coverage under COBRA. They must request continuation within _____ days following termination.

Answer 8

3 months

31 days

Question 9

All health plans that provide coverage to family members of the insured, must provide coverage for the insured’s newborn child from

Answer 9

the moment of birth, and for a period of 31 days.

Question 10

If a premium is required to continue the newborn’s coverage, it must be paid

Answer 10

within the 31-day period

Question 11

Coverage includes injury and sickness, including medical care for

Answer 11

diagnosed congenital defects and birth abnormalities

Question 12

This is the period during which a person is eligible for Part A benefits under Medicare. A _____ day _____ _____ will begin with each spell of illness and commence the day the patient is admitted to a hospital. This benefit period ends when an individual has been out of the hospital for a period of _____ _____. There is no limit to the number of _____ _____ benefit periods a person can have.

Answer 12

Benefit Period (Medicare Part A)

90 day

60 consecutive days

90 day

Question 13

The free look period for Medicare Supplements is:

Answer 13

30 days

Question 14

The open enrollment period for Medicare (and Medicare Supplements) begins _____ _____ before your _____ birthday and lasts for _____ months.

Answer 14

3 months before your 65th birthday and lasts for 7 months

Question 15

An insurer may exclude coverage for a preexisting condition on a Medicare Supplement Policy for up to _____ months.

Answer 15

6 months.

Question 16

Medicare Supplement policies must contain this renewable provision in TN:

Answer 16

Guaranteed Renewable

Question 17

A Medicare Supplement policy may be suspended for up to _____ months at the request of a policyholder in the event he or she becomes eligible for _____ benefits.

Answer 17

twenty-four months

medicaid

Question 18

Long-term care insurance is designed to provide coverage for diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services in a setting other than an ____________________________.

Answer 18

acute care unit of a hospital.

Question 19

Long-term care insurance is any policy designed to provide coverage for at least _____ _____ _____ for each covered person on an expense-incurred, indemnity, prepaid, or other basis

Answer 19

12 consecutive months

Question 20

A _____ _____ _____ must be on the first page of each long-term care policy delivered in. It explains that some long-term care costs may not be covered.

Answer 20

“notice to buyer”

Question 21

An _____ _____ _____ is required in a long term care policy and provides a very brief description of the important features of the policy. It is considered a summary of coverage.

Answer 21

outline of coverage

Question 22

IN a Long Term Care policy, for a policy or certificate that has been in force for less than _____ months, an insurer may rescind a long term care insurance policy or deny a claim by showing misrepresentation material to acceptance for coverage. For a policy in force between _____ months and _____ years, an insurer may rescind or deny a claim only if any material misrepresentation pertains to the condition for which benefits are sought.

After being in force for _____ years, it is not contestable on the grounds of misrepresentation alone. Intent must be demonstrated.

Answer 22

6 months

6 months and 2 years

2 years

Question 23

Exclusion or limitation of benefits on the basis of Alzheimer’s Disease is NOT permitted in

Answer 23

Long Term Care policies.

Question 24

Long term care free look policy is

Answer 24

30 days long.

Question 25

All insurers issuing long-term care insurance policies must offer, as an optional benefit, an _____ _____ feature which provides for automatic future increases in the level of benefits without evidence of insurability. Adjustments must be at a level which provides reasonable protection from future increases in the costs of care for which benefits are provided.

Answer 25

inflation protection

Question 26

Long-term care policies must pay for _____ _____ care at the _____ _____ _____ as paid for a nursing home if the insured meets the qualifications for nursing home care.

Answer 26

“at-home”

same daily amount

Question 27

Before selling any long-term care policy, an insurance producer must have an Accident and Health producer’s license and also complete an approved

Answer 27

8 hour long-term care training course.

Question 28

Every insurer authorized to issue an individual or group accident and sickness insurance policy in this State that provides _____ ______ _____ coverage and that includes coverage for any female should provide coverage for one annual ______ screening test in conjunction with an annual ______ _____ for covered females who are not more than ______ years of age if the screening test is determined to be medically necessary.

Answer 28

major medical insurance

chlamydia

pap smear

29 years

Question 29

At the same time that a health carrier sends notice of a final adverse decision regarding a health claim, the carrier shall notify the aggrieved person in writing of the right to request an _____ _____ of that decision.

• The health carrier must describe both the standard and expedited procedures highlighting the provisions that give the aggrieved person the opportunity to submit additional information and any forms used to process an external review
• Additional information can be submitted in writing to the ______ ______ organization within _____ business days of the person’s receipt of notice that the person is eligible and accepted for external review
• The _____ ______ organization must review all information and documents submitted by an aggrieved person within ______ business days of receipt. A decision must be reached in _____ _____. It must then report its decision to the health carrier within _____ calendar days. The health carrier then has _____ calendar days to notify the aggrieved party of that decision

Answer 29

external review

6 business days

6 business days

40 days

2 calendar days

3 calendar days

Question 30

______ dentistry is the procedure for restoring the function and integrity of a missing tooth structure. Examples include

Answer 30

Restorative

fillings, crowns, and dental bridges.

Question 31

Oral and maxillofacial surgery is surgery to treat many diseases, injuries and defects in the

Answer 31

head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region.

Question 32

Endodontics is the branch of dentistry dealing with diseases of the _____ _____. Root canals would be an example. Endodontics is commonly _____ _____ from a dental policy.

Answer 32

dental pulp

excluded or limited

Question 33

Periodontics is a dental specialty that involves the prevention, diagnosis and treatment of disease of the supporting and surrounding tissues of _________________. It also involves the maintenance of the health, function, and esthetics of these structures or tissues.

Answer 33

the teeth or their substitutes

Question 34

Prosthodontics is a branch of dentistry dealing with the replacement of missing parts using biocompatible substitutes such as:

Answer 34

bridgework or dentures

Question 35

The treatment of irregularities in the teeth (esp. of alignment and occlusion) and jaws, including the use of braces, is known as:

Answer 35

Orthodontics

Question 36

A _____ _____ ______ of the cost of dental services may be required whenever the patient requires dental treatment

Answer 36

pre-treatment estimate

Question 37

Dental plans are typically indemnity plans, which pay benefits based on a

Answer 37

predetermined, fixed rate set for the services provided…regardless of the actual expenses incurred.

Question 38

The absence of deductibles on routine examinations encourages

Answer 38

preventive care in dental insurance

Question 39

Dental treatment expenses required to repair an injury would normally be covered under a

Answer 39

hospital or medical expense policy.

Question 40

Some _____ _____ _____ _____ _____ will provide coverage for some dental related services related to the _____ _____ _____ _____. Some of these include: reduction of any facial bone fractures; removal of tumors; treatment of dislocations, facial and oral wounds/lacerations in order to repair an injury; and the removal of cysts or tumors of the jaws or facial bones.

Answer 40

hospital and medical expense plans

jaw or facial bones

Question 41

“Exchanges” are created by this health reform bill to help individuals and small businesses purchase health insurance coverage. The purposes of the exchange include:

• Reduce the number of uninsured in the state
• Facilitate the purchase and sale of qualified health plans in the individual market
• Assist qualified employers in the state in enrolling their employees in qualified health plans
• Assists individuals in accessing public programs, premium tax credits, and cost-sharing reductions

Answer 41

Affordable Care Act (ACA)

Question 42

• Certify health plans as qualified, based on pre-determined criteria
• Utilize individual, unique formats for presenting health benefit plan options
• Verify and resolve inconsistent information provided to the exchange by applicants

Answer 42

Roles performed by the health insurance exchange under the Affordable Care Act (ACA).

Question 43

The Affordable Care Act will be funded through a variety of channels including the health insurance tax for individuals and families who forego health coverage, and increase in Medicare tax for incomes above _____, a _____ excise tax on medical device manufacturers, a tax on cadillac health plans, a new tax on tanning businesses, an additional _____ tax on investment gains from dividends, rental income, capital gains and dividends including the sale or personal or commercial real estate. In addition, the allowable deduction for unreimbursed medical expenses has changed from 7.5% to _____. A tax credit will be provided for individuals and families purchasing insurance through the _____.

Answer 43

$200,000

2.3% excise tax

3.8% tax

10%

Marketplace

Question 44

There are four tiers of “qualifying health plans” you or your employer can purchase on the exchange. They range from lower quality, but more affordable “_____ _____”, to “_____ _____” to a more expensive plan with better coverage called a “_____ _____”.

There is also a “Platinum plan” which is the highest quality and cost plan. Lower premium plans will have higher deductibles, less benefits and larger out of pocket costs.

The actuarial level is calculated as the percentage of total average cost for covered benefits that a plan will cover. * Bronze Plans: 60% actuarial level of coverage provided

Answer 44

Bronze plans

Silver Plans

Gold Plans

Platinum Plan

Question 45

• Bronze Plans: _____ actuarial level of coverage provided
• Silver Plans: _____ actuarial level of coverage provided
• Gold Plans: _____ actuarial level of coverage provided
• Platinum Plans: _____ actuarial level of coverage provided

Answer 45

60%

70%

80%

90%

Question 46

Health plans cannot limit or deny benefits or deny coverage for a child younger than age _____ because of _____ _____. This applies to both group and individual policies

Answer 46

19

preexisting conditions

Question 47

The ACA prohibits health plans from putting _____ _____ _____on most benefits that are received by an insured.

• For plans starting on or after _____ _____ _____, but not before _____ _____ _____, the annual dollar limit is _____ _____. After _____ _____ _____, there are no annual dollar limits
• Plans are allowed to put an annual dollar limit on health care services that are _____ _____ _____.

Answer 47

lifetime dollar limits

September 23, 2012

January 1, 2014

$2 million

January 1, 2014

not considered essential

Question 48

These are plans that were purchased before _____ _____ _____. These plans do not have to follow the ACA’s rules and regulations or offer the same benefits, rights and protections as new plans. An exception to this is:

• Such a plan:

Answer 48

Grandfathered plans

March 23, 2010

cannot impose lifetime limits on how much health care coverage people may receive

Question 49

As defined by the Affordable Care Act, the MAXIMUM amount an individual can contribute to a Flexible Savings Account is

Answer 49

$2,500

Question 50

Low-income individuals and families whose incomes are between _____ and _____ of the federal poverty level will receive federal subsidies on a sliding scale if they purchase insurance via an exchange

Answer 50

100% and 400%

Question 51

According to the Affordable Care Act, if a large employer does NOT provide health insurance and owes an employer mandate penalty, the annual penalty is calculated by multiplying _____ by the number of full time employees minus _____.

Answer 51

$2,000

30

Question 52

State law does not permit producers to charge an _____ _____ for services that are customarily associated with the sale, solicitation, negotiation or servicing of insurance policies.

Answer 52

additional fee

Question 53

The Commissioner notifies the association of an insolvent insurer no later than _____ days after receiving notice of the insurer’s insolvency.

Answer 53

3 days

Question 54

Which of these is a valid Tennessee regulation for referral fees?

Answer 54

The Commissioner may establish by rule a maximum amount for each referral.

Question 55

All of these statements regarding referrals are true EXCEPT:

Answer 55

Referral fees must be filed and approved with the Commissioner of Insurance.

(Referral fees do not have to be filed and approved with the Commissioner of Insurance. However, the Commissioner may establish by rule a maximum amount for each referral that occurs in the state.)