página 3/17 12.3.1. HMO Operation HMOs operate almost exclusively through group enrollment plans. An HMO may be owned or sponsored by insurance companies or service companies, but an HMO can…

página 4/17 Prepaid Limited Health Service Organization – PLHSO A PLHSO is any person, corporation, partnership, or other entity, that in exchange for an advance payment, is compromised to provide…

página 5/17 The contract, certificate, or member handbook must be accompanied by an identification card containing at least the following:   The name that the organization offers or the contract…

página 6/17 What requirements does the Florida law contains on maternity coverage if a contract of health insurance or HMO include such coverage?   The Florida statutes require that a…

página 7/17 Requirements related with HIV/AIDS Before the test, the insurer will disclose its intention to test a person for HIV infection or for a specific disease or medical condition…

página 8/17 Exclusive Provider Organization (EPO) Exclusive Provider means a provider of healthcare, or a group of providers of healthcare, which have established a written agreement with the insurer to…

página 9/17 Special Enrollment Period (SEP) for the Working Aged and Working Disabled People who do not enroll in Part B or premium Part A when eligible for the first…

página 10/17 Free Look A policy presented at the Office as supplemental Medicare should:  Contain a definition of “eligible Medicare spending,” which is nothing more than the types of health…

página 11/17 The scheme will be delivered to the applicant submitting the application and with the exception of the direct response policy, it should be given acknowledgment of receipt or…

página 12/17   A Medicare supplement policy or certificate must have the benefits which are designed to meet the cost-sharing amounts under Medicare. They will automatically change to match any…

página 13/17 Post-hospital home health care services (including nursing care, therapy, and the part-time services of home health aides) The first 20 days are covered in full contingent upon the…

página 14/17 12.6.3. Medicare Part C – Medicare Advantage Due to increased eligible participants, programs and Medicare options have been renovated to include Medicare Part C (formerly known as Medicare…

página 15/17 However, if the total drug costs of a beneficiary are more than $6,440, after the beneficiary would have spent another $4,550, then coverage begins again and beneficiaries will…

página 16/17 The project also gives governors more flexibility to design Medicaid benefits, which efficiently and affordably meet the needs of their states and control gaps that allowed people game…

página 17/17 The following is a list of standard coverages: If a worker dies in an accident, the law provides the payment of funeral expenses (up to a limit) and…

página 1/8    LESSON 13 MEDICAL EXPENSE INSURANCE   SUBJECT Purpose of Medical Expense Insurance Basic Medical Expense Plans Major Medical Expense Plans Other Types of Medical Expense Coverage  ——————————————————————————————————————————…

página 2/8 SECTION 13.1: Purpose of Medical Expense Insurance Basic medical expenses insurance (often referred to as first dollar insurance) pays benefits “in advance” without the patient having to pay…

página 3/8 Medical Reimbursement Plan – Medical Indemnity Plan Medical Reimbursement Plan and Medical Indemnity Plan are two different approaches with respect to medical plans. In a medical reimbursement plan,…

página 4/8 Relative Value Scale The relative value scale assigns points to surgical procedures rather than dollar figure. For example, the establishment of a broken finger naturally leads to a…

página 5/8 Major Medical policy provides limits on high profits. It can be used as a separate comprehensive plan or be a supplement to the basic plan. When rising medical…

página 6/8 High Deductible Health Plans (HDHP) A High Deductible Health Plan or HDHP offers low premiums, but requires that the insured pays a relatively high deductible. For a person…

página 7/8 Family deductibles and out-of-pocket expense caps are twice as individual spending. HSA individuals that are 55 years and older can make additional catch -up contributions of $1,000 (2012,…

página 8/8 Discount Medical Plan Organization – DMPO Discount Medical Plan is an arrangement or contract in which a person, for a fee or other consideration, give you access to…

página 1/6   LESSON 14 DISABILITY INCOME INSURANCE   SUBJECT Purpose of Disability Coverage Disability Income Benefits Disability Income Policy Provisions Policy Exclusions  Policy Riders —————————————————————————————————————————– LECCIÓN 14 SEGURO DE…

página 2/6 SECTION 14.1: Purpose of Disability Income Insurance The need for disability income often overlooked. People often associate it with a life insurance, health insurance and even with annuities…

página 3/6 Using the approach of percent-of-income gains (percent-of-earnings approach) policies may vary the amount of benefits to be paid according to the length of disability. For example, the company…

página 4/6 Residual Benefits Amount A residual amount of the benefit is based on the proportion of income actually lost the insured, due to partial disability, taking into account the…

página 5/6 14.3.7. Non-Disabling Injury Provision Some people who have a disability income policy may suffer a disability that is not severe enough to qualify to receive income benefits. This…

página 6/6 14.5.2. Social Security Rider Social Security Annex provides additional income when social security benefits (Social Security, Workers Compensation and Government Programs) are not being received by the insured;…

página 1/3 LESSON 15: ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE-AD&D SUBJECT AD&D Benefits Other Forms of AD&D  ————————————————————————————————————————————-   LECCION 15: SEGURO DE MUERTE, ACCIDENTAL Y DESMEMBRAMIENTO-AD&D  TEMAS Beneficios AD&D Otras…

página 2/3 SECTION 15.1: AD&D Benefits Accidental Death and Dismemberment (AD & D) is usually covered in group insurance plans. These can be written in different ways: Basic Medical Expense…

página 3/3 SECTION 15.2: Other Forms of AD & D Limited risk policies provide accidental death or dismemberment by a particular cause; normally, aviation (which is excluded in most other…

página 1/13 LESSON 16 PRIVATE INSURANCE PLANS FOR SENIORS   SUBJECT Medicare Supplement Policies Long-Term Care (LTC) Insurance ——————————————————————————————————————   LECCION 16 PLANES DE SEGUROS PRIVADOS PARA MAYORES – PARA…

página 2/13 SECTION 16.1: Medicare Supplement Policies The protection of our elderly citizens; the high costs of medical care includes plans to provide long-term care and supplemental insurance plans. NAIC…

página 3/13 16.1.2. Medigap Plans Before June 1, 2010 there were 12 standardized Medigap plans, now there are 10 (Plans A to D, F, G and from K to N).…

página 4/13 DISCLOSURE An insurance policy care qualified long-term (long-term care insurance), must include a statement of disclosure or disclosure within policy and within the statement of coverage, the policy…

página 5/13 POLICY STANDARDS Free Look The insured shall have thirty days after the delivery of an individual policy of long-term care to examine it and return it to the…

página 6/13 Minimum Coverage All policies provide long-term care coverage for at least 24 consecutive months for each person covered for care in a nursing home. All policies provide long-term…

página 7/13 Acute Illness Acute illness is a serious illness that with proper medical treatment, the patient should receive a full recovery (such as influenza) Chronic Illness Chronic illness is…

página 8/13 Adult Day Care Day care centers for adults usually cater to those who are mentally or physically affected, or when other primary care are not accessible. The center…

página 9/13 In general, these associations have four objectives: To stimulate the availability of high quality, safe private long-term care Remove the fear of impoverishment resulting from the need to…

página 10/13 The diagnosis of chronic disease can be done on two levels. Physical Cognitive   A physical diagnosis mean that the individual has been certified as unable to perform…

página 11/13 The provision for renewal of the new policy should be revised in order to ensure that their rights periodically renew the policy.   A direct response insurer issued…

página 12/13 In the case of an applicant who chooses not to appoint an additional person, the resignation must indicate:   Protection against involuntary lapse: I understand that I have…

página 13/13   The insurer may use Form OIR-B2-1786 (1/2007) State Association Disclosure Notice (Partnership Status Disclosure Notice), which was approved and incorporated by reference standard. This notice is provided…

página 1/7 LESSON 17: HEALTH INSURANCE POLICY PROVISIONS SUBJECT NAIC Model Health Insurance Policy Provisions Common Exclusions or Restrictions Renewability Provisions  —————————————————————————————————————–   LECCIÓN 17: PROVISIONES EN PÓLIZA DE SEGURO…

página 2/7 SECTION 17.1: NAIC Model Health Insurance Policy Provisions NAIC (National Association of Insurance Commissioners) developed the Uniform Act Provisions Health Insurance Policies in which 23 provisions described order.…

página 3/7   Payment of Claims: Payment of providing specific claims how and to what claims payments must be made.   Physical Exam and Autopsy: The provision of physical examination…

página 4/7   Conformity with State Statutes: All disputes concerning the statutes of the state where the insured lives, are automatically set at the time the policy is issued.  …

página 5/7 Employee Life The life of a group of individual employees of an employer may be insured by the employer benefits from different persons, under a group policy issued…

página 6/7 Waiver for Impairment Impairment exemptions are used in those areas where a person may have preexisting conditions and still be considered uninsurable. These exemptions exempt specific reasons for…

página 7/7   Guarantee Policy Renewable (Renewable Guaranted Policies) In this type of policy, the insurer has promised that the insured’s policy is renewable, usually up to a certain age…

página 1/6 LESSON 18: HEALTH INSURANCE UNDERWRITING AND PREMIUMS SUBJECT Major Risk Factors in Health Insurance Classification Risk Health Insurance Premium Factors Tax Treatment of Health Insurance Premiums and Benefits…

página 2/6 SECTION 18.1: Major Risk Factors in Health Insurance Key factors evaluated in the underwriting process health insurance are often the same as in all insurance underwriting processes, with…

página 3/6 18.1.4. Occupation Again, anyone involved in a dangerous occupation presents a higher risk. For example, a pilot may present a higher than a person who spends his time…

página 4/6 Interest Just as life insurance, a portion of the premiums are invested to earn interest. This is an important element setting tariffs. Interest income can reduce premium costs.…

página 5/6 SECTION 18.4: Managed Care Managed Care Organizations (MCO) include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO) and Exclusive Provider Organizations (EPO). These contain medical costs and is…

página 6/6 Case Management It is a process that can be deterred by expensive claims. Case managers (CMS) are medical specialists within the insurance company who review cases that can…

página 1/28   FLORIDA SPECIFIC LAWS AND RULES LESSON 19 LAWS AND RULES PERTINENT TO LIFE AND HEALTH INSURANCE SUBJECT Financial Services Regulation Insurers Marketing Practices Code of Ethics Policy…

página 2/28 SECTION 19.1: Financial Services Regulation   19.1.1. Department of Financial Services The Department of Financial Services is headed by the Chief Financial Officer and the Commissioner of Insurance,…

página 3/28 The Office, within existing resources, can spend the funds for professional development of its employees, including, but not limited to, professional fees for employees who are required to…

página 4/28 What role does the Office of Insurance Regulation [OIR]? OIR is responsible for all activities of the Financial Services Commission relating to the regulation of insurance companies and…

página 5/28 19.1.3. Office of Financial Regulation In addition to other powers conferred by Florida Statutes, the Office of Financial Regulations provides: [Sec. 655.012]   General Supervisory Powers; Rulemaking:  …

página 6/28 19.1.4. The State Legislature The State Legislature establishes and maintains the legal framework of state laws on insurance (Insurance Code / The Insurance Code). The legislature established the…

página 7/28 Leeway or “Basket” Provision The Insurance Code contains this provision detailing the terms that allow domestic insurers the right to invest in a certain percentage of its total…

página 8/28 Using the status or licensed as a licensed insurance agent and in any form in connection with placing business with an entity authorized does not include, but are…

página 9/28 A registered agency is not subject to mandatory or discretionary denial, suspension or revocation, however, if any of the directors of the agency registered commits a violation of…

página 10/28 Agents are required to maintain documentation of transactions for three years if the transaction involves the payment of premiums. Florida law requires an agent written report to the…

página 11/28 The insurance agent has the responsibility to provide the public, customers and potential customers the best policies to suit the needs of the individual and the prospect or…

página 12/28 Churning Churning is defined as the practice by which the values of the policy in a life insurance contract or existing annuity is used to buy another policy…

página 13/28 Section 19.4: Code of Ethics The National Association of Life Underwriters (The National Association of Life Underwriters) works for the best interest of policyholders and development opportunities of…

página 14/28 How do you approach the Code of Ethics defamation? Knowingly making, publishing, broadcasting or circulating, directly or indirectly, or assisting, incitement, or encourage manufacturing, publishing, broadcasting or circulating…

página 15/28 For the purposes of this section, the term “individual health insurance” coverage health insurance as described in s. 627.6561 (5) (a) 2., is offered to a person in…

página 16/28 19.5.4. Mental and Nervous Disorders Florida Statutes require all health insurers must provide an optional group in the policy coverage for mental and nervous disorders. This does not…

página 17/28 19.05.13. Bones and Joints of the Jaw and Facial Region Under Florida law, if coverage for diagnostic procedures, including the bones and joints of the skeleton is included;…

página 18/28 Required and optional coverage The word “primary care physician” or “doctor” (“physician” or “medical doctor”) when used in any insurance policy health service plan health care, or other…

página 19/28   This subsection shall not be construed as may affect any other coverage under this part or restrict the scope of coverage of any policy, plan or contract.…

página 20/28 Section 19.7: Group Life Insurance / Group Life Insurance The life insurance group is the same as health insurance or coverage for medical expenses, as to the basics.…

página 21/28 Section 19.9: Retirement Plans Florida law does not regulate retirement plans. ERISA supersedes any state law. ERISA administers standards for funding, participation and vesting, termination of insurance, disclosure,…

página 22/28 Section 19.11: Types of Health Plans an insurance policy of group health issued is required or provided outside the State of Florida to cover a Florida resident to…

página 23/28 19.12.1. Modified Community Rating Community property classification means that all small groups enjoy the same prices for everyone in the same category or class. It must be identical…

página 24/28 Anyone who is a resident of Florida are eligible for coverage under the plan, if the person has been denied coverage for health insurance for at least two…

página 25/28 Guaranteed-Issue Basis: It means an insurance policy to be offered to an employer, employee or dependent of the employee, regardless of their health status, preexisting conditions, or claims…

página 26/28 Disclosure requirements In connection with the offering of a health benefit plan for a small business, a carrier small employer:   You must make a reasonable disclosure and…

página 27/28 Fair Marketing Standards Each carrier employer small (small employer carrier) must actively market the plan coverage health benefits, including standard health benefit basic plans and including any later…

página 28/28 Benefit Plans Offered A carrier Small Employer shall submit to the office, in a format and manner prescribed by the committee, a plan standard health a high deductible…

página 1/9   LESSON 20 AGENT LICENSING. DEFINITIONS SUBJECT Licensing Maintaining a License Unfair Trade Practices Unfair Claims Settlement Practices Definitions  ——————————————————————————————————————————- LECCIÓN 20 AGENTES LICENCIADOS. DEFINICIONES SUBJECT / TEMAS…

página 2/9 Section 20.1: Licensing The Florida statutes provide that no person may be, act as, or advertising or advertise himself as an insurance agent, insurance adjuster or customer representative…

página 3/9 Licensing Requirements The applicant for an insurance license must submit a written application, complete under oath and signed by him, where the required conditions are met and pay…

página 4/9 Cada licenciado, excepto un agente de seguros de título, debe completar un curso de actualización de 5 horas cada 2 años, que es específico para la licencia en…

página 5/9 Acciones Penales y Administrativas / Criminal and Administrative Actions)   Administrativa / Administrative Dentro de 30 días después de la disposición final de una acción administrativa tomada en…

página 6/9 SECCIÓN 20.3: PRACTICAS DESLEALES DE COMERCIO / UNFAIR TRADE PRACTICES   Las sanciones en Florida por violar la Ley de Prácticas Comerciales Desleales son libertad condicional, suspensión o…

página 7/9 20.3.5. DISCRIMINACIÓN INJUSTA / UNFAIR DISCRIMINATION   A las aseguradoras se les prohíbe mostrar ningún tipo de parcialidad hacia las personas en lo que respecta a sus primas…

página 8/9   SECCIÓN 20.5: DEFINICIONES / DEFINITIONS   Transacción de Seguros / Insurance Transaction. Las disposiciones del Código de Seguros definen el término transacciones de seguros como:   solicitud…

página 9/9   Certificado de Autoridad / Certificate of Authority Antes de que cualquier entidad puede operar como una aseguradora en este estado, debe obtener un certificado de autoridad de…

página 1/   PL _ SEGUROS DE SALUD Y VIDA Y ANUALIDADES (INCLUYENDO CONTRATOS VARIABLES)   DOLPHY INSURANCE SCHOOL   Esto no es una muestra del examen oficial de licencia…