2025 West Virginia Health Insurance Licensing Exam
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Questions and Answers
What is the role of the gatekeeper in an HMO plan? ---------- Correct Answer ------------ To
control costs for the services of specialists
Small employer is any person or entity engaged in business in West Virginia who employs an
average of ____ or less employees (but at least two eligible employees and employees). -----------
Correct Answer ------------ 50
The West Virginia Health Insurance Plan was established to provide health insurance to residents
of West Virginia, who has been rejected or refused issue of health insurance by at least _____
insurer, and is unable to obtain insurance. ----------- Correct Answer ------------ one
What types of injuries and services will be excluded from major medical coverage? ----------
Correct Answer ------------ Injuries caused by war, intentionally self-inflicted injuries, injuries
covered by workers compensation, regular dental/vision/hearing care, custodial care, and elective
cosmetic surgery
Who chooses a primary care physician in an HMO plan? ---------- Correct Answer ------------ The
individual member
Permanent Total Disability benefits under West Virginia Workers Compensation laws are
calculated as: ---------- Correct Answer ------------ 66 2/3% of the claimants average weekly wage
at the time the injury occurred, as long as the amount does not exceed 100% of the average
weekly wage in West Virginia.
Which of the following may act on behalf of the Commissioner in the event he or she is unable
to attend a hearing? ---------- Correct Answer ------------ Any person designated by the
Commissioner. .
Joe, a West Virginia insurance agent, has written and placed insurance on a resident of this state
with an insurer that is not licensed to do business in West Virginia. Who is responsible in the
event of a claim under this policy? ---------- Correct Answer ------------ The agent Joe because, in
West Virginia, agents are personally responsible for policies they write with unlicensed insurers.
What is the term for a period of time immediately following a disability, during which benefits
are not payable? ---------- Correct Answer ------------ Elimination period
In what type of health plans are providers paid for services in advance, regardless of the services
provided? ---------- Correct Answer ------------ Prepaid plans
In order to be eligible for coverage by an HSA, an individual must also be covered by what type
,of health plan? ---------- Correct Answer ------------ High Deductible Health Plan (HDHP)
Can an insured who belongs to a POS plan use an out-of-network physician? ---------- Correct
Answer ------------ Yes, but the copays and deductibles may be higher
What will determine the length of the grace period in a health insurance policy? ---------- Correct
Answer ------------ The mode of the premium payment
How will changing one's occupation to be more hazardous affect the health insurance policy in
force? ---------- Correct Answer ------------ Claim benefits will be reduced to what the premium
would have bought for a more hazardous occupation
Under an individual disability income policy, the benefits must be paid on at least what
schedule? ---------- Correct Answer ------------ monthly
According to the Reinstatement provision, once a lapsed policy is reinstated, how soon will
coverage be available for accidents? ---------- Correct Answer ------------ immediately
What is a probationary period in group health insurance? ---------- Correct Answer ------------
The period of time that must lapse before an employee is eligible for group health coverage
Which health insurance provision describes the insured's right to cancel coverage? ----------
Correct Answer ------------ Renewal provision
The insured on a health policy misstated his age on the insurance application. If this
misrepresentation is discovered, what will happen to the policy? ---------- Correct Answer --------
---- The benefit amount payable under the policy will be adjusted to the insured's correct age.
After the elimination period, a totally disabled insured qualified for benefits from a disability
income policy that has a waiver of premium rider. What will happen to the premium that was
paid into the policy during the elimination period? ---------- Correct Answer ------------ Premium
will be refunded
What is the purpose of the coinsurance provision and health insurance policies? ---------- Correct
Answer ------------ To prevent overutilization of the policy benefits
What health policy provision describes the insured right to cancel coverage? ---------- Correct
Answer ------------ Renewability provision
What are usual/reasonable and customary charges based on? ---------- Correct Answer ------------
Average charge for a given procedure in the specific geographic area
What health policy provision prevents the insured from bringing a lawsuit against the insurance
company for at least 60 days after proof of losses provided? ---------- Correct Answer ------------
Legal actions
,If a health insurance policy has a 31 day grace, period, what does that mean? ---------- Correct
Answer ------------ The policy remains in effect for 31 days after the premium is due and not paid
According to the time limit on certain defenses provision in health insurance policies, when can
an insurer contest fraudulent missstatements on a health insurance application? ---------- Correct
Answer ------------ Anytime while the policy is in force
If the insured pays a monthly premium for health insurance, how long would the grace period be
on the policy? ---------- Correct Answer ------------ 10 days
What health policy provision states to whom the claim benefits must be paid? ---------- Correct
Answer ------------ Payment of Claims
Who decides which optional provisions would be included in a health policy? ---------- Correct
Answer ------------ insurance company
What does the free look period allow the insured to do? ---------- Correct Answer ------------
Return the policy for a full refund of premium within a specified time period (usually 10 days)
What is the name of the act by the insured to voluntarily give up insurance? ---------- Correct
Answer ------------ cancellation
What is a deductible and a health insurance policy? ---------- Correct Answer ------------ A
specified dollar amount that the insured must pay before the insurer pays any policy benefits.
What section of the health insurance policy lists the services for which the insurer will not
provide coverage? ---------- Correct Answer ------------ Exclusions
What health policy provision allows the insured a period of time to examine the policy and
determine whether to keep it? ---------- Correct Answer ------------ Free-look period
What health policy provision defines the insured's duty to provide the insurer with reasonable
notice in the event of a loss? ---------- Correct Answer ------------ Notice of claim
What provision provides for the sharing of expenses between the insured and the insurance
company? ---------- Correct Answer ------------ Coinsurance
When can an irrevocable beneficiary be changed? ---------- Correct Answer ------------ With the
written consent of the beneficiary
What is the main difference between coinsurance and co-pay? ---------- Correct Answer -----------
- Co-pay is a set dollar amount; coinsurance is a percentage of the expenses
What will happen to a health insurance policy if the premium has not been paid by the end of the
grace period? ---------- Correct Answer ------------ The policy will be cancelled
, A waiver of premium provision may be included with what type of health insurance policies? ----
------ Correct Answer ------------ Disability Income
Who pays the expense for an autopsy under the physical examination and autopsy provision? ----
------ Correct Answer ------------ insurer
What is another name for Medicare Advantage plans? ---------- Correct Answer ------------ Part C
At what age do individuals qualify for Medicare? ---------- Correct Answer ------------ age 65
In which Medicare supplemental policies are the core benefits found? ---------- Correct Answer --
---------- All plans (A-N)
An insurer with Medicare Part D has reached the initial benefit limit and must now pay a portion
of prescription drugs costs. What is the term for this gap in coverage? ---------- Correct Answer --
---------- The donut hole
Who qualifies for Medicaid? ---------- Correct Answer ------------ Persons with insufficient
income
What benefits are provided by Medicare Part C? ---------- Correct Answer ------------ Expanded
benefits for a fee through private insurance programs such as HMO's or PPO's.
Medicare Part A will pay for what type of services? ---------- Correct Answer ------------ Inpatient
hospital care, skilled nursing facility care, home health care and hospice care
What part of Medicare is known as hospital insurance? ---------- Correct Answer ------------ Part
A
Who qualifies for Medicare coverage? ---------- Correct Answer ------------ People age 65 or
older, or anyone who has been entitled to Social Security disability income benefits for 2 years,
or who has chronic kidney disease
What is the purpose for Medicare Supplement plans? ---------- Correct Answer ------------ To fill
in the gaps in Medicare coverage
How many pints of blood with be paid for by Medicare Supplement core benefits? ----------
Correct Answer ------------ First 3 pints
How does someone qualify for Social Security disability income benefits? ---------- Correct
Answer ------------ The insured must have the proper insured status (such as fully insured), meet
the definition of disability, and satisfy the waiting period
How is Part B Medicare funded? ---------- Correct Answer ------------ By monthly premiums and
from the general revenues of the federal government
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