Life & Health Insurance — Health Provisions, Group & Medicare flashcards
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NAIC uniform mandatory and optional health provisions, renewability, coordination of benefits, group health, COBRA, HIPAA, the Affordable Care Act, Medicare Parts A to D and enrollment, Medigap, Medicaid and LTC partnership programs.
Learn deck · part of Life and health insurance producer licence (national portion) · written against: Life, accident and health concepts common to state producer exams; NAIC model provisions; federal law as of 2026; state law excluded. Updated 2026-10-10.
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Under the NAIC Uniform Individual Accident and Sickness Policy Provision Law, what is the difference between mandatory and optional provisions?Mandatory provisions must appear in every individual health policy; optional provisions may be included, but only in the model's wording or wording no less favorable to the insured.Health Policy Provisions › Mandatory Provisions
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A producer promised a health insured an extra benefit that is not in the policy. What does the entire contract provision say about such promises?That the policy, endorsements and attached papers are the whole contract, and no producer may change it or waive its provisions; only an approved change signed off by an insurer's officer counts.Health Policy Provisions › Mandatory Provisions
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What does the time limit on certain defenses provision prevent once its period has passed?The insurer can no longer void the policy or deny a claim over non-fraudulent misstatements in the application, or deny a claim as pre-existing unless the condition was excluded by name or specific description.Health Policy Provisions › Mandatory Provisions
Watch out: the NAIC model text says three years, but many states, and much exam prep, use two. -
What grace periods does the NAIC model require for individual health policies?At least 7 days for weekly-premium policies, 10 days for monthly-premium policies and 31 days for all others, with coverage continuing during the grace period.Health Policy Provisions › Mandatory Provisions
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Why can a group health plan cover employees without medical underwriting of each one?The group is underwritten as a whole, judging its size, makeup, industry and claims history, and it must exist for a purpose other than buying insurance.Group Health & Federal Law › Group Health
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How does a contributory group plan differ from a noncontributory one in participation?In a noncontributory plan the employer pays all of the premium and every eligible employee must be covered; in a contributory plan employees share the cost, and a minimum percentage of eligible employees, commonly 75 percent, must enroll.Group Health & Federal Law › Group Health
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What is the purpose of a probationary (waiting) period for new employees in a group plan?To make new hires wait a set time before becoming eligible, which controls turnover cost and adverse selection.Group Health & Federal Law › Group Health
Watch out: under the ACA, a group plan's waiting period cannot exceed 90 days. -
Who is eligible for Medicare?People 65 or older, people under 65 who have received Social Security disability benefits for 24 months, and people with end-stage renal disease.Medicare & Medicaid › Medicare
Watch out: people with ALS qualify as soon as their disability benefits begin. -
Who gets Medicare Part A without paying a premium?People who, or whose spouse, worked and paid Medicare taxes for at least 40 quarters (about ten years).Medicare & Medicaid › Medicare
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What does Medicare Part A cover?Inpatient hospital care, skilled nursing facility care after a qualifying hospital stay, hospice and some home health care.Medicare & Medicaid › Medicare
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About these cards
Review status: Second-reader reviewed, with corrections applied.
Checked against:
- Checked against the NAIC Uniform Individual Accident and Sickness Policy Provision Law, the NAIC Group Coordination of Benefits Model Regulation, the NAIC Group Health Insurance Standards Model Act, Group Health Insurance Mandatory Conversion Privilege Model Act and Small Group Market Health Insurance Coverage Model Act, and the NAIC Medicare Supplement Insurance Minimum Standards Model Act and its model regulation, as commonly adopted; state versions vary.
- Federal items checked against the Internal Revenue Code, ERISA, COBRA, HIPAA, the Affordable Care Act and their regulations (26 CFR 54, 29 CFR 2590, 45 CFR 147, 156, 160 and 164, 42 CFR 407, 409, 411 and 422), and CMS Medicare publications (Medicare & You, Choosing a Medigap Policy); public domain U.S. government sources.
- General insurance principles written from author knowledge; no textbook, prep-course or question-bank text copied. National content only: state insurance law, fees and figures indexed yearly are excluded.
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Not insurance or legal advice. These cards cover the national portion of the producer licensing exam only. State insurance law and your state's exam content are not included; check your state's insurance department and its candidate handbook.
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