guarantee exam

On individual health insurance policies, an insurer must furnish the claimant with claim forms within how many days?

15 days

Florida law requires that both individual and group health insurance policies provide coverage for a newborn child of a covered family member, other than the insured, for a period of

18 months

During policy solicitation, an insurer exaggerates the financial condition of one of its competitors, and makes it sounds worse than it is. This is an example of an unfair trade practice of

Defamation.

An employee has just started working for a small group corporation and works 25 hours per week. The employee is

Eligible to receive full health coverage.

What does Basic Medical Expense cover?

Nonsurgical services a physician provides

Ed is covered under a health plan provided by his employer. He was told that his insurance would pay the majority of the covered expenses if he would choose to see a provider in his plan's list. If Ed chose to be treated by a provider who was not on the list, his portion of the bill would be greater. Ed is covered under a/an

Preferred Provider Plan.

All health insurance policies are required to contain

Uniform Mandatory Provisions, which are specific provisions that are required to be in every health insurance contract. An insurer may add provisions that are not in conflict with the uniform provisions, provided that the provision is approved by the state in which the policy is delivered. These additional provisions are not catalogued.

fraternal benefit society

must operate for the benefit of its members and their beneficiaries.

Premium payment mode

refers to the frequency the policyowner pays the premium.

If the insured misstated his or her age at the time of the application, the benefits

the benefits paid will be those that the premium would have purchased at the correct age.

preferred provider plan

the insurer has contracted with certain providers to provide services at a certain rate. If an insured chooses to be treated by another provider who does not have a contract with them, the coinsurance rate could be reduced, with the insured paying a higher percentage of the charges.

Agents are required to report ______ information to the Department

-Change of address. -Administrative actions. -Use of assumed names.

An applicant misstates his age on his application for a health insurance policy. He states that he is 39, but his actual age is 49. When he files a claim, what will most likely happen?

Benefits paid will be those that would have been purchased at the correct age

The "stop-loss" feature on a major medical policy is intended to

Establish a maximum amount of out-of-pocket expense that an insured will have to pay for medical expense in a calendar year.

An insured needs ongoing treatment for a diabetic condition. Under PPACA, which of the following is correct?

The condition must be covered under the insured's plan.

All of the following are true of a Multiple Employer Trust (MET) EXCEPT

The employee has a right of conversion upon leaving the group coverage.

Employees that are covered under a MET

have no conversion rights when they leave the trust.

After age 31, the number of work credits required to receive benefits varies, but at least

20 of those credits must have been earned in the 10 years immediately prior to becoming disabled. Those age 62 or older must have accumulated at least 40 work credits.

Joe, age 63, was disabled and can no longer work. He meets the Social Security definition of total disability. How many work credits must Joe have accumulated to have the status of fully insured?

40

The insured must wait ____ days after proof of loss, before legal action can be brought against the company.

60

All of the following could qualify as a group for the purpose of purchasing group health insurance EXCEPT

An association of 35 people.

Agents in this state are required to promptly report all of the following to the Department EXCEPT

Change in marital status.

An insurer that operates for one or more social, educational, charitable, benevolent, or religious purposes for the benefit of its members is known as a

Fraternal insurer.

Which of the following terms refers to solicitation, negotiation, effectuation or advising related to an insurance contract?

Insurance transaction

Which of the following statements is INCORRECT?

Medicare and Medigap policies provide coverage for long-term custodial or nursing home care. however, Medicare and Medigap policies do not provide coverage for long-term custodial or nursing home care. Medicare will cover nursing home care if it is part of the treatment for a covered injury or illness. Medicare and Medicare supplements pay for skilled nursing care, but the coverage is limited. Medicaid does pay for nursing home care, but it provides coverage only for those that qualify with low income and low assets.

The frequency and the amount of the premium payment are known as what?

Premium mode

What does the application of contract of adhesion mean?

Since the insured does not participate in preparing the contract, any ambiguities would be resolved in favor of the insured. take-it-or-leave-it basis. Because the insured does not have input in drafting the policy but simply adheres to the terms of the policy, the policy is classified as a contract of adhesion. Any uncertain terms in the policy will be interpreted in favor of the insured.

Once the initial benefit limit in Medicare Part D is reached, how is the beneficiary affected?

The beneficiary is then responsible for a portion of prescription drug costs.

HMO contracts may only be sold by

a licensed and appointed health insurance agent or a full-time salaried employee or officer of an HMO who devotes most of his or her services to activities other than soliciting HMO contracts from the public and who receives no commissions or compensation for procuring such contracts.

Defamation

against the law for any person to make, publish, or circulate any oral or written statement or literature that is false, maliciously critical of or substantially misrepresents the financial condition of any insurer, and which is intended to injure any person engaged in the insurance business.

"Eligible employee" means

an employee who works full time, having a normal workweek of 25 or more hours, and who has met any applicable waiting-period requirements or other requirements. Eligible employees include a self-employed individual, a sole proprietor, a partner of a partnership, or an independent contractor, but does not include a part-time, temporary, or substitute employee.

Under PPACA

chronic conditions, like diabetes, must be covered as an essential service under the plan. Lifetime or annual treatment dollar limits are not allowed

HMO contracts may only be sold by a licensed and appointed health insurance agent or a full-time salaried employee or officer of an HMO who devotes most of his or her services to

Activities other than soliciting HMO contracts from the public and who receives no commissions or compensation for procuring such contracts.

Which of the following statements is NOT true regarding health insurance policy provisions?

All additional provisions written by insurers are cataloged by their respective states.

All of the following must sign an application for health insurance EXCEPT the

Insurer.

The guaranteed purchase option is also referred to as the

Future increase option.

All of the following are features of catastrophic plans EXCEPT

High premiums.

A stop-loss feature is a provision that

gives the insured financial security by limiting the maximum amount that would have to be paid in deductibles and co-payments during a calendar year.

The term "insurance transaction"

includes solicitation, negotiation, effectuation or advising related to an insurance contract.

Basic Medical Expense Coverage

is often referred to as Basic Physicians Nonsurgical Expense Coverage provides coverage for nonsurgical services a physician provides. The benefits, however, are usually limited to visits to patients confined in the hospital. Some policies will also pay for office visits. There is no deductible with benefits, but coverage is usually limited to a number of visits per day, limits per visit, or limits per hospital stay.

Health insurance applications require the signatures of

the proposed insured, the policyowner (if different than the insured), and the agent or producer.

Catastrophic plans

usually have lower monthly premiums and high deductibles.

An employee that becomes ineligible for group coverage because of termination of employment or change in status, must exercise extension of benefits under COBRA

Within 60 days.

Each insurer appointing an agent, adjuster, service representative, customer representative, or managing general agent in Florida must file all appointments with the __________ and, at the same time, pay the applicable appointment fee and taxes.

department

For Medicare Part D Once the initial benefit limit is reached

the beneficiary is responsible for paying 25% of prescription drug costs.

An individual long-term care policy cannot be issued until the insurer has received from the applicant a written designation of at least

1 person.

Under the mandatory uniform provision Legal Actions, an insured is prevented from bringing a suit against the insurer to recover on a health policy prior to

60 days after written proof of loss has been submitted.

If an insurer appoints a customer representative, the appointment needs to be filed with which of the following entities?

Department