Ok-Life-Accident-and-Health-or-Sickness-Producer Exam Dumps : Oklahoma Life, Accident, and Health or Sickness Producer Exam

For individuals aged 65 or older who are still working and covered by an employer’s group health plan, Medicare’s role depends on the employer’s size. For employers with fewer than 20 employees (as in this case with 18 employees), Medicare is typically theprimary payer, and the group health plan is secondary. However, if the individual is actively working and enrolled in the group plan, the group plan is primary, and Medicare acts as thesecondary payer, covering claims not fully paid by the group plan, as per Medicare Secondary Payer (MSP) rules.

Option A: Incorrect. The group health plan is primary for active employees, not Medicare.

Option B: Correct. Medicare acts as the secondary insurer, paying claims not fully covered by the group plan.

Option C: Incorrect. Medicare does cover claims as a secondary payer, not denying them to prevent overinsurance.

Option D: Incorrect. Medicare does not require cancellation of group insurance; individuals can maintain both.

This question aligns with the Prometric content outline under “Medicare,” which covers Medicare’s coordination with group health plans.

To calculate the insured’s payment:

Deductible: The insured pays the first $1,000 of the $5,000 procedure cost.

Remaining cost: $5,000 - $1,000 = $4,000.

Coinsurance: The policy has 80/20 coinsurance, so the insurer pays 80% ($3,200) and the insured pays 20% ($800) of the $4,000.

Total paid by insured: $1,000 (deductible) + $800 (coinsurance) = $1,800.

Out-of-pocket maximum: The policy’s $3,000 out-of-pocket maximum caps the insured’s total payments. Since $1,800 is less than $3,000, the insured pays $1,800. However, the question asks for the total paid “towards the $5,000,” and the out-of-pocket maximum of $3,000 suggests a cap on total liability for covered expenses. In this context, the correct interpretation is that the insured’s payment is capped at the out-of-pocket maximum if applicable, but standard calculation yields $1,800, and the answer options suggest a possible intent for the maximum.

Upon review, the correct calculation yields $1,800 (Option C), but the out-of-pocket maximum of $3,000 (Option B) may be the intended answer if the question implies the maximum liability. Given the standard insurance calculation,Option C ($1,800)is mathematically correct, butOption B ($3,000)aligns with the out-of-pocket maximum as a potential cap. Since the calculation is clear, we selectC.

Corrected Answer: C

Explanation of Calculation:

Deductible: $1,000.

Coinsurance: 20% of $4,000 = $800.

Total: $1,000 + $800 = $1,800.

The out-of-pocket maximum ($3,000) is not reached, so the insured pays $1,800.

Option A: Incorrect. The insured does not pay the full $5,000 due to insurer contributions.

Option B: Incorrect. The $3,000 out-of-pocket maximum is not reached; the calculated payment is $1,800.

Option C: Correct. The insured pays $1,800 based on the deductible and coinsurance.

Option D: Incorrect. The $1,000 deductible alone does not account for coinsurance.

This question aligns with the Prometric content outline under “Provisions, Options, Exclusions, Riders, Clauses, and Rights,” which covers health insurance cost-sharing provisions.

Oklahoma insurance regulations mandate that health insurance policies providing child immunization coverage must not impose certain restrictions that could limit access to these benefits. Specifically, the Oklahoma Insurance Code, Title 36 O.S. § 6060.3, states that "benefits for immunizations required under child immunization coverage shall not be subject to prior authorization requirements." This ensures that children can receive necessary immunizations without delays caused by insurer approval processes.

The Oklahoma Life, Accident, and Health or Sickness Producer Study Guide further clarifies, "Child immunization benefits must be provided without prior authorization to promote timely access to preventive care. However, benefits may still follow a recommended immunization schedule or be subject to other policy terms like deductibles, unless otherwise specified." Options A, B, and D are not explicitly prohibited under the law, making option C the correct answer.