Ohio Health Insurance Practice Exam Free - 2026

• A. A hearing examiner appointed by the superintendent of insurance
• B. An accredited independent review organization
• C. A peer review panel selected by the health plan issuer
• D. The Ohio Life and Health Insurance Guaranty Association

Correct answer: B. An accredited independent review organization

Explanation: Ohio's external review process under ORC Chapter 3922 assigns the review to an accredited independent review organization, which is independent of the issuer that made the determination. A panel chosen by the issuer would defeat the purpose of external review, the guaranty association handles insolvencies rather than benefit disputes, and departmental hearing examiners are not the reviewers under this chapter. See ORC 3922.01.

• A. Any decision to deny payment for an out-of-network service
• B. A determination that has been reviewed and reversed by an independent review organization
• C. The issuer's first written denial of a requested health care service
• D. An adverse benefit determination upheld at the completion of the issuer's internal appeals process

Correct answer: D. An adverse benefit determination upheld at the completion of the issuer's internal appeals process

Explanation: Ohio defines an adverse benefit determination as a decision to deny, reduce, or terminate a requested service or payment in whole or in part, and it becomes a final adverse benefit determination only once it is upheld at the completion of the issuer's internal appeals process. The initial denial has not yet been through internal appeal, a reversed determination is no longer adverse, and the network status of the service is not what makes a determination final. See ORC 3922.01.

• A. A subscriber contract of a health insuring corporation marketed primarily to supplement Medicare reimbursements
• B. A long-term care policy marketed to persons enrolled in Medicare Part B to cover custodial nursing home care
• C. A Medicare Advantage plan under contract with Medicare that replaces original Medicare hospital and medical coverage
• D. A group disability income policy designed to supplement Social Security disability benefits for persons over 65

Correct answer: A. A subscriber contract of a health insuring corporation marketed primarily to supplement Medicare reimbursements

Explanation: Ohio's definition expressly reaches group and individual sickness and accident policies, health insuring corporation subscriber contracts, and other issuers' contracts advertised, marketed, or designed primarily to supplement Medicare reimbursements for hospital, medical, or surgical expenses. Long-term care and disability income coverage are different product categories, and a plan that replaces original Medicare is not supplementing reimbursements under it. See ORC 3923.33.

• A. Sixty-five years of age or older, whether or not the individual has enrolled in Medicare
• B. Both sixty-five years of age or older and enrolled for benefits under Medicare Part B
• C. Enrolled for benefits under Medicare Part A, whether or not the individual has reached sixty-five
• D. Retired and no longer eligible for coverage under an employer-sponsored group health plan

Correct answer: B. Both sixty-five years of age or older and enrolled for benefits under Medicare Part B

Explanation: Ohio's rule ties open enrollment to the first month in which both conditions are met: the individual is at least sixty-five and is enrolled for benefits under Medicare Part B. Age alone, Part A enrollment alone, or loss of employer coverage does not start the six-month window under this rule. See OAC 3901-8-08.

• A. A time when all cosmetic procedures are covered
• B. A period when premiums are waived automatically
• C. A waiting period for auto collision coverage
• D. A period before certain dental benefits are available

Correct answer: D. A period before certain dental benefits are available

Explanation: Some dental policies use waiting periods before certain services, especially major services, become covered. The exact waiting period depends on the policy.

• A. It often helps pay for routine eye exams, lenses, frames, or contacts subject to plan limits
• B. It pays the full cost of eye surgery and treatment of eye disease, with no plan limits
• C. It is a required component of every adult major medical plan sold under the ACA
• D. It reimburses eyewear and exams at 100 percent once the major medical deductible is met

Correct answer: A. It often helps pay for routine eye exams, lenses, frames, or contacts subject to plan limits

Explanation: Vision coverage is typically a limited-benefit plan for routine eye care and eyewear, subject to allowances, copays, networks, and frequency limits.

• A. Any sickness diagnosed after the policy's effective date
• B. A named disease or group of diseases listed in the policy
• C. Preexisting conditions that a major medical plan has excluded
• D. Accidental injuries, with sickness excluded from coverage

Correct answer: B. A named disease or group of diseases listed in the policy

Explanation: Specified disease policies provide benefits for named conditions, such as cancer, according to policy definitions and limits.

• A. Keep premiums level regardless of the insured's age at issue
• B. Extend the benefit period so benefits are paid for life
• C. Help benefits keep pace with rising care costs over time
• D. Shorten the elimination period as care costs rise over time

Correct answer: C. Help benefits keep pace with rising care costs over time

Explanation: Inflation protection can increase benefit amounts over time so long-term care benefits are less likely to lose purchasing power as care costs rise.

• A. Open enrollment poster
• B. Producer appointment
• C. Copayment
• D. Benefit period

Correct answer: D. Benefit period

Explanation: The benefit period describes the maximum length of time or total pool of benefits available under a long-term care policy, depending on the policy design.

• A. The contract issued to the employer or group sponsor
• B. The certificate issued to each employee covered under the plan
• C. The enrollment application signed by each employee
• D. The summary of benefits given to eligible group members

Correct answer: A. The contract issued to the employer or group sponsor

Explanation: In group coverage, the master policy is issued to the employer or group sponsor, while covered individuals usually receive certificates or summaries of coverage.

• A. The full contract terms, which control over the master policy
• B. Evidence and summary of the member's coverage under the group policy
• C. Ownership rights in the master policy, with the right to amend it
• D. A guarantee that the coverage will continue after employment ends

Correct answer: B. Evidence and summary of the member's coverage under the group policy

Explanation: A certificate explains the member's coverage under the group plan, but the master policy controls the full contract terms.

• A. Only the employer may file claims
• B. Coverage applies only after Medicare begins
• C. Employees pay part of the premium cost
• D. The insurer contributes to every employee's retirement account

Correct answer: C. Employees pay part of the premium cost

Explanation: In a contributory plan, covered employees pay part of the premium. Participation rules may apply to reduce adverse selection.