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Insurance Licensing InsNV_Health02 Exam Syllabus Topics:

Section Objectives
Health Insurance Policy Provisions - Mandatory and Optional Provisions
  • 1. Policy requirements and clauses
    • 2. Renewability provisions
      - Claims and Benefits
      • 1. Benefit determination and payment
        • 2. Claim procedures
          Insurance Basics - Insurance Contracts
          • 1. Contract elements
            • 2. Policy provisions, riders, and exclusions
              - Risk Management and Insurance Concepts
              • 1. Types of risk and methods of handling risk
                • 2. Insurance principles and contract characteristics
                  Government Health Insurance Programs - Medicare
                  • 1. Medicare supplement insurance
                    • 2. Medicare parts and eligibility
                      - Medicaid and Other Programs
                      • 1. Medicaid eligibility and coverage
                        General Insurance Regulation - Nevada Insurance Department and Regulatory Authority
                        • 1. Insurance laws, rules, and regulations
                          • 2. Commissioner of Insurance powers and duties
                            - Licensing Requirements and Responsibilities
                            • 1. Continuing education and license maintenance
                              • 2. Producer licensing requirements
                                Accident and Health Insurance Fundamentals - Medical Expense Insurance
                                • 1. Major medical plans
                                  • 2. Hospital, surgical, and physician expense coverage
                                    - Types of Health Insurance Policies
                                    • 1. Individual health insurance
                                      • 2. Group health insurance
                                        • 3. Managed care plans
                                          - Disability Income Insurance
                                          • 1. Disability definitions and benefits
                                            • 2. Elimination periods and benefit periods
                                              Producer Duties and Ethics - Ethical Responsibilities
                                              • 1. Consumer protection requirements
                                                • 2. Fiduciary responsibilities
                                                  - Sales Practices
                                                  • 1. Advertising and marketing rules
                                                    • 2. Unfair trade practices

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                                                      Insurance Licensing NV Accident and Health 認定 InsNV_Health02 試験問題 (Q18-Q23):

                                                      質問 # 18
                                                      An insured has a $1,000 deductible and then pays 20% of covered medical expenses, while the insurer pays
                                                      80%. What is the insured's 20% share called?

                                                      • A. Coinsurance
                                                      • B. Stop-loss benefit
                                                      • C. Elimination period
                                                      • D. Copayment

                                                      正解：A

                                                      解説：
                                                      Coinsurance is the percentage of covered expenses that the insured shares with the insurer after the deductible has been satisfied. In this question, the insured pays 20% and the insurer pays 80%; this is commonly described as 80/20 coinsurance. The deductible is separate. It is the amount the insured must pay before the insurer begins sharing covered expenses, subject to any services that the policy covers before the deductible.
                                                      A copayment is a fixed dollar amount paid for a covered service, such as a stated amount for a physician visit or prescription. It is not normally expressed as a percentage. An elimination period is a waiting period in disability-income insurance before benefits begin. A stop-loss feature, also called an out-of-pocket maximum in many plans, limits the insured's covered cost sharing after a stated maximum has been reached, subject to plan rules.
                                                      Understanding these terms is essential when comparing health plans. A plan may have a lower premium but a higher deductible, greater coinsurance, or a larger out-of-pocket maximum. Producers must clearly explain the consumer's potential financial responsibility and must not imply that the insurer pays every medical expense once a policy is issued.
                                                      References/topics from the Study Guide: Major Medical Insurance; Deductibles; Coinsurance; Copayments; Out-of-Pocket Maximums.


                                                      質問 # 19
                                                      For a group health plan subject to the federal waiting-period rule, the waiting period for otherwise eligible employees generally may not exceed:

                                                      • A. 30 calendar days
                                                      • B. 60 calendar days
                                                      • C. 90 calendar days
                                                      • D. 180 calendar days

                                                      正解：C

                                                      解説：
                                                      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.


                                                      質問 # 20
                                                      Which of the following is NOT a preventive benefit for adults?

                                                      • A. Skin cancer screening
                                                      • B. High blood pressure screening
                                                      • C. Mammograms
                                                      • D. Physical therapy

                                                      正解：A

                                                      解説：
                                                      Skin cancer screening is the correct answer because it is not included as a broadly required preventive benefit for adults in the same manner as the other listed services. Preventive-service requirements are tied to specified recommended services and may vary by population, risk status, and recommendation level. A service may be medically useful or covered by a particular policy without being a universally required no-cost preventive benefit.
                                                      High blood pressure screening is a standard adult preventive screening. Mammography is a recognized preventive screening benefit for eligible women. Physical therapy can be included in preventive fall- intervention services for certain adults, particularly older adults at risk of falls, when the preventive-service criteria are met. Thus, the question is testing the distinction between services commonly covered in some circumstances and services specifically identified as preventive benefits.
                                                      Skin examinations or skin cancer evaluations may be medically necessary when a lesion, symptom, prior diagnosis, or risk factor is present. In that circumstance, the service may be classified as diagnostic rather than preventive and can be subject to policy terms and cost sharing.
                                                      For examination purposes, remember that preventive-benefit questions focus on the mandated screening list and preventive-care criteria, not merely on whether a service can be medically valuable.
                                                      Study Guide references/topics: preventive care; adult screenings; in-network preventive benefits; adult preventive-care benefits .


                                                      質問 # 21
                                                      Under an individual health policy issued in Nevada, a newborn is automatically covered for a MAXIMUM of how many days after birth?

                                                      • A. Five
                                                      • B. Thirty-one
                                                      • C. Ten
                                                      • D. Two

                                                      正解：B

                                                      解説：
                                                      A newborn is automatically covered under the applicable Nevada health-policy rule for 31 days after birth.
                                                      Coverage begins from the moment of birth and includes necessary care and treatment for injury or sickness, including medically diagnosed congenital defects and birth abnormalities.
                                                      To continue coverage beyond the initial 31-day period, the policy may require timely notice of the birth and payment of any additional premium or fee required by the insurer. The notification and payment requirement must be satisfied within the 31-day period if the policy requires it. This rule protects newborns during the immediate post-birth period, when medical care may be urgently necessary.
                                                      The automatic coverage is not limited to routine newborn care. It includes necessary treatment of medical conditions identified at birth, subject to the policy's applicable limits. The law also prevents the policy from excluding premature births under the mandated newborn coverage.
                                                      Two, five, and ten days are incorrect because they would not provide the statutory protection required for newborn coverage. The exam point is that the initial automatic period is 31 days, while continuation beyond that period may require prompt enrollment action by the insured.
                                                      Study Guide references/topics: individual health insurance; newborn coverage; congenital defects; notification requirements; Nevada newborn-coverage requirements .


                                                      質問 # 22
                                                      If coverage has stayed in force with the same insurance company, what is the maximum number of years for which reconstructive surgery (mastectomy) benefits must be provided?

                                                      • A. 0
                                                      • B. 1
                                                      • C. 2
                                                      • D. 3

                                                      正解：B

                                                      解説：
                                                      If reconstructive surgery is begun within three years after a mastectomy, the amount of benefits for that surgery must equal the amount provided by the policy at the time of the mastectomy. Therefore, the tested maximum period is three years.
                                                      Nevada requires a policy that covers mastectomy to provide commensurate coverage for reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to create symmetry, prostheses, and treatment of physical complications of all stages of mastectomy, including lymphedema. The attending physician and patient determine the appropriate care.
                                                      The three-year rule protects an insured from losing the original level of reconstruction benefits merely because reconstruction is delayed. If surgery begins more than three years after the mastectomy, benefits are governed by the policy terms, conditions, and exclusions in effect at the time reconstructive surgery begins.
                                                      This question does not ask how long all reconstruction coverage disappears. It tests the period during which the policy must preserve the benefit amount available at the time of mastectomy.
                                                      Study Guide references/topics: mastectomy coverage; reconstructive surgery; breast reconstruction; mandated health benefits; NRS 689B.0375 .


                                                      質問 # 23
                                                      ......

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