ACCIDENT AND HEALTH INSURANCE EXAM 6
HIGH-YIELD POLICY PROVISIONS, CLAIMS,
AND MANAGED CARE SUMMARY 2026
◉ The difference between pre-certification and concurrent review is
that pre-certification
-costs more to the patient
-is considered a cost containment measure
-occurs before the treatment is provided
-costs less to the patient.
Answer: occurs before the treatment is provided
◉ The Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA) applies ONLY to employers with which number of
employees?
-5 or more
-20 or more
-50 or more
-15 or more.
Answer: 20 or more
,◉ Susan is insured through her Group Health Insurance plan and
changed her coverage to an individual plan with the same insurer
after her employment was terminated. This change is called a(n)
-crossover
-conversion
-exchange
-extension of benefits.
Answer: conversion
◉ Small employers who are sponsored by an insurer to provide
group benefits to its employees are called
-MEWA
-Lloyd of London
-Fraternal Benefit Society
-Surplus lines brokers.
Answer: MEWA
◉ Self-insured group health programs may be administered by all of
the following organizations EXCEPT
-an actuary
-an administrative-services-only arrangement
-a third-party administrator
-an insurance company.
,Answer: an actuary
◉ Ron has a new employer and wishes to enroll in the company's
group health plan. In determining whether his pre-existing health
condition applies, Ron cannot have more than a ___ day gap without
previous health insurance.
-75
-63
-45
-90.
Answer: 63
◉ One technique that helps to control health care costs is a
requirement for
-Preexisting conditions
-Second surgical opinions
-Waiver of premiums
-Optional benefit riders.
Answer: Second surgical opinions
◉ Minimum participation standards exist for group health insurance
plans in order to
-avoid treating benefits as taxable income
, -cover the agent's commission
-meet state requirements
-prevent adverse selection.
Answer: prevent adverse selection
◉ In which of the following processes will the insurer oversee the
insured's hospital stay to confirm everything is going according to
schedule and that the insured will be released as planned?
-Pre-certification review
-Congruent review
-Concurrent review
-Pretense review.
Answer: Concurrent review
◉ If a patient with a preferred provider organization (PPO) chooses
to use a non-PPO, the patient usually can expect
-To pay the full cost of care
-To have higher out-of-pocket expenses
-100% reimbursement for the service provided
-A one year waiting period before re-enrolling in the PPO.
Answer: To have higher out-of-pocket expenses
HIGH-YIELD POLICY PROVISIONS, CLAIMS,
AND MANAGED CARE SUMMARY 2026
◉ The difference between pre-certification and concurrent review is
that pre-certification
-costs more to the patient
-is considered a cost containment measure
-occurs before the treatment is provided
-costs less to the patient.
Answer: occurs before the treatment is provided
◉ The Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA) applies ONLY to employers with which number of
employees?
-5 or more
-20 or more
-50 or more
-15 or more.
Answer: 20 or more
,◉ Susan is insured through her Group Health Insurance plan and
changed her coverage to an individual plan with the same insurer
after her employment was terminated. This change is called a(n)
-crossover
-conversion
-exchange
-extension of benefits.
Answer: conversion
◉ Small employers who are sponsored by an insurer to provide
group benefits to its employees are called
-MEWA
-Lloyd of London
-Fraternal Benefit Society
-Surplus lines brokers.
Answer: MEWA
◉ Self-insured group health programs may be administered by all of
the following organizations EXCEPT
-an actuary
-an administrative-services-only arrangement
-a third-party administrator
-an insurance company.
,Answer: an actuary
◉ Ron has a new employer and wishes to enroll in the company's
group health plan. In determining whether his pre-existing health
condition applies, Ron cannot have more than a ___ day gap without
previous health insurance.
-75
-63
-45
-90.
Answer: 63
◉ One technique that helps to control health care costs is a
requirement for
-Preexisting conditions
-Second surgical opinions
-Waiver of premiums
-Optional benefit riders.
Answer: Second surgical opinions
◉ Minimum participation standards exist for group health insurance
plans in order to
-avoid treating benefits as taxable income
, -cover the agent's commission
-meet state requirements
-prevent adverse selection.
Answer: prevent adverse selection
◉ In which of the following processes will the insurer oversee the
insured's hospital stay to confirm everything is going according to
schedule and that the insured will be released as planned?
-Pre-certification review
-Congruent review
-Concurrent review
-Pretense review.
Answer: Concurrent review
◉ If a patient with a preferred provider organization (PPO) chooses
to use a non-PPO, the patient usually can expect
-To pay the full cost of care
-To have higher out-of-pocket expenses
-100% reimbursement for the service provided
-A one year waiting period before re-enrolling in the PPO.
Answer: To have higher out-of-pocket expenses
