Wisconsin Health Insurance Exam 2026
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233 Terms
What is a Material Fact?
Information that would affect an insurer's underwriting decision.
What are the Four Elements of a Legal Contract?
Consideration, Agreement, Legal purpose, and Competent parties (CALC)
What is Consideration?
The premium paid by the insured and the insurer's promise to pay claims.
What is Concealment?
Failing to disclose a material fact.
What is Total Disability?
The inability to perform the duties of one's occupation.
What is Residual Disability?
A partial loss of income due to disability.
Employer-Paid Disability Premiums
Benefits are taxable to the employee.
What is Managed Care?
A system designed to control healthcare costs and quality.
Where is the Master Policy issued?
Issued to the employer.
What is a Certificate of Insurance?
A document provided to employees that summarizes the benefits and coverage of a group insurance plan.
Contributory Plan
Employees pay part of the premium.
What is an Noncontributory Plan?
Employer pays the entire premium.
What does COBRA do?
Allows continuation of group health coverage after a qualifying event.
What does Preventive Dental Care entail?
Exams, cleanings, and routine services.
Basic Dental Care
Fillings and simple restorative procedures.
Major Dental Care
Crowns, bridges, dentures, and oral surgery.
What is an Annual Maximum?
The most a dental policy will pay in a policy year.
Medicare Part A
HOSPITAL and inpatient services.
What does Medicare Part B cover?
MEDICAL and outpatient coverage.
What does Medicare Part C cover?
MEDICARE ADVANTAGE plans offered by private insurers.
What does Medicare Part D cover?
Prescription DRUG coverage.
What are the Six Actions of Daily Living (ADLs)?
Bathing, dressing, eating, toileting, transferring, and continence.
What does Inflation Protection on a policy do?
Increases benefits to help offset rising care costs.
How does Medicare interact with Long-Term Care?
Medicare generally DOES NOT cover long-term custodial care.
Employer-Paid Health Insurance Premiums
Generally not taxable to employees.
Health Insurance Benefits
Generally received tax-free.
Employer-Paid Disability Premiums
Benefits are taxable.
Employee-Paid Disability Premiums
Benefits are tax-free when premiums are paid with after-tax dollars.
License Revocation
A permanent removal of an insurance license.
What is an Aleatory Contract?
An agreement where values exchanged may be unequal.
Adhesion Contract
A contract prepared by one party with little negotiation.
What is an Insurable Interest?
A financial interest in preserving life or property from loss.
Guaranteed Renewable
The insurer cannot cancel coverage, but premiums may increase by class.
What does a Conditionally Renewable policy allow the insurer to do?
The insurer can terminate coverage under stated conditions.
Orthodontic Services
Treatment involving correction of TEETH ALIGNMENT.
Endodontics
Treatment involving the INTERIOR of a tooth, such as root canals.
Periodontics
Treatment involving GUMS and supporting structures.
Usual, Customary, and Reasonable (UCR)
Common reimbursement standard based on local charges.
Original Medicare
Coverage consisting of Part A and Part B.
Dual Eligibility
Qualifying for both Medicare and Medicaid.
What is Custodial Care?
Care that assists with daily living activities.
Home Health Care
Medical or personal care provided in the home.
Adult Day Care
Supervised care provided during daytime hours. Allows the individual to live at home.
What is Nursing Home Care?
Skilled and custodial care provided in a facility.
What is a benefit amount?
Maximum daily or monthly benefit payable.
What is the Benefit Duration?
The length of time benefits may be paid.
What does Nonforfeiture Benefit do?
Provides a reduced benefit if coverage lapses.
What does Coordination of Benefits (COB) do?
Determines which insurer pays first when multiple policies exist.
What is the Free-Look Period?
Time during which a policy can be returned for a full refund.
What is a Contingent Beneficiary?
A receiver of benefits if the primary beneficiary cannot.
Who is the Master Contract Owner?
The employer
Where Is the Master Contract Kept?
With the employer or plan sponsor.
Employee Rights Under a Master Contract
Employees have coverage but do not own the policy.
Group Health Insurance
Typically issued under a master contract.
Foreign Insurer
An insurer incorporated in another STATE.
Alien Insurer
An insurer incorporated in another COUNTRY.
Producer Address/Residence Change
Must be reported to the Wisconsin Commissioner of Insurance within 30 days.
How does coverage work for a Disabled Dependent?
Coverage may continue beyond age 26 if the child is incapable of self-support because of a mental or physical disability and meets policy requirements.
When does a newborn have be added to a policy?
Typically within 31 days.
Newborn Coverage
Coverage begins at birth.
COBRA Election Period
60 days.
COBRA Continuation Coverage
18 months for termination or reduction of hours.
Proof of Loss
Usually must be submitted within 90 days of loss.
When does reinstatement of a policy after a lapse occur?
Policy generally reinstated automatically after 45 days if insurer does not respond; 10 days for sickness
Legal Action Against Insurer
Cannot be brought until 60 days after proof of loss and within 3 years after.
What does the Time Payment of Claims entail?
Claims must be paid immediately after receiving proof of loss.
Claim Forms
Insurer has 15 days to provide claim forms after notice of claim.
Notice of Claim
Must be given within 20 days after a loss occurs.
Long-Term Care Free Look
30 days.
Social Security Disability and Medicare
Eligible for Medicare after 24 months of disability benefits.
Policyholder Examination
The Commissioner does not routinely examine individual insureds or policyholders.
Commissioner's Investigative Authority
Limited to insurance companies, producers, agencies, and insurance-related activities.
What’s COBRA Premium Limit?
The employer may charge up to 102% of the premium for continued coverage.
What is Medigap?
Private insurance that supplements Original Medicare. Must be enrolled in Medicare Part A and Part B.
What does Medicare Plan F entail?
It covers almost all Medicare out-of-pocket costs.
What does Medicare Plan G entail?
Covers almost all Medicare out-of-pocket costs but DOES NOT pay the Medicare Part B deductible.
What does Medicare Plan N do?
Lower premium in exchange for more cost sharing.
What is an Own Occupation disability?
Cannot perform own job but can train for another job. Easier to qualify for.
Probationary Period
The waiting period before a new employee becomes eligible for group coverage.
What is Any Occupation disability?
Cannot perform ANY job. Harder to Qualify for.
Assignment
The transfer of OWNERSHIP rights in a policy from one party to another. LIFE INSURANCE.
The transfer of BENEFITS in a policy from one party to another. HEALTH INSURANCE.
Medicare Supplement insurance is also known as
Medigap
Conversion Privilege
Allows an insured leaving a group plan to obtain individual coverage
Conversion Privilege requires
No evidence of insurability
Medicare part that covers hospice care
Medicare Part A
Which federal law allows employees to choose among benefit options using pretax dollars?
Section 125 Cafeteria Plan
Insurance intermediaries must maintain records for:
3 years
Request for hearings must be made within how many days of each other?
30 days
Hearings must be held within 10 to ______ days following the request for hearing
60 days
What is the maximum fine per day for noncompliance with an order?
$5000
What is the civil penalty fine for failure to obey an order?
$1000
What is the civil penalty fine for violation per law or regulation?
$1000
What is the civil penalty for firm to act by its agent?
$1,000
What is the maximum corporate criminal penalty fine per offenser?
$10,000
What is the maximum imprisonment time for criminal penalties?
up to 3 years
What is the minimum age to receive and intermediary's license?
18 years old
What is the total hours required in prelicensing education?
20 hours
Records must be maintained for at least ______ years
3 years
The commissioner may issue a temporary intermediary license for a maximum of _________ year(s) to a surviving spouse, business partner, or employee if an intermediary die, becomes disabled, or is called to active military service
1 year
For an intermediary appointment an insurer must file a notice of appointment within _________ days of the agency contract or first insurance application
15 days