FLorida State Health Insurance Exam Latest 2024-2025. Questions & Correct Answers. Grade A, Exams of Insurance law

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FLorida State Health Insurance Exam Latest

2024-2025. Questions & Correct Answers.

Graded A

"Notice to the Applicant" - ANSMust be issued to all applicants. Informs the applicant that a credit report will be ordered which shows past history and if any other health insurance they previously applied. THE AGENT MUST LEAVE THIS NOTICE WITH THE APPLICANT

1. ACTUAL CHARGE - ANSTHE AMOUNT THE PHYSICIAN OR SUPPLIER BILLS FOR SERVICES 2 LTC CONTRACTS - ANS2 TYPES OF LTC CONTRACTS:
2. INDIVIDUAL LONG TERM CARE IS THE MOST COMMON (THE ADVANTAGES OF AN INDIVIDUAL LTC INCLUDE STATE REGULATION, GUARANTEED RENEWABLE, AND THE ABILITY TO CUSTOMIZE THE PLAN TO ONE'S NEEDS
3. GROUP AND VOLUNTARY LTC CONTRACTS

(GROUP LTC OFFERS LOWER RATES AND LESS UNDERWRITING, A LLOWING

SOMEONE WHO MIGHT BE DENIED TO ENROLL DURING OPEN ENROLLMENT

PERIODS.

***NOTE:: NOT ALL STATES REGULATE GROUP LTCs 2 TYPES OF FSA - ANS2 TYPS FSA:

1. HEALTH CARE ACCOUNT 2)) DEPENDENT CARE ACCOUNT (QUALIFIED DEPENDENT UNDER AGE 13 THAT CAN BE CLAIMED AS AN EXEMPTION ON A FEDERAL TAX RETURN A SPOUSE OR A DEPENDENT THAT IS PHYSICALLY/MENTALLY UNABLE TO CARE FOR THEMSELVES

3 OPTIONS FOR MEDICARE PART A PARTICIPANTS - ANS1) INITIAL ENROLLMENT

PERIOD

THIS IS WHEN AN INDIVIDUAL BECOMES ELIGIBLE FOR MEDICARE (3 MONTHS

BEFORE TURNING 65, AND ENDING 3 MONTHS AFTER THE 65TH BIRTHDAY)

2) GENERAL ENROLLMENT PERIOD

JANUARY 1 AND MARCH 31, EACH YEAR

3) SPECIAL ENROLLMENT PERIOD

ANYTIME DURING THE YEAR, IF THE INDIVIDUAL OR HIS/HER SPOUSE IS STILLED

EMPLOYED AND COVERED UNDER A GROUP PLAN

3 TYPES OF DISABILITY POLICIES FOR BUSINESS OWNERS - ANSBUSINESS OWNERS

DISABILITY POLICIES

3 TYPES:

1) OVERHEAD EXPENSES

(RENT, UTILITIES, EMPLOYEES SALARIES, INSTALLMENT PURCHASES, LEASED

EQUIPMENT)

2) KEY PERSON DISABILITY

(DISABILITY PURCHASED ON AN KEY EMPLOYEE, IN WHICH THERE WOULD OCCUR

AN ECONOMIC LOSS, SHOULD HE NO LONGER WORK FOR THE COMPANY, IT WILL

COVER THE EXPENSE OF TRAINING A REPLACEMENT

3) DISABILITY BUY-SELL INSURANCE

(A LEGAL AGREEMENT IS PREPARED BY AN ATTORNEY WHICH SPECIFIES HOW THE

BUSINESS WILL PASS BETWEEN OWNERS, IF ONE SHOULD DIE OR BECOME

DISABLED)

A CLAIM FOR LOSS OR DISABILITY "AFTER 2 YEARS" - ANSAFTER 2 YEARS FROM

DATE OF POLICY ISSUE, A CLAIM CAN NOT BE "REDUCED OR DENIED" ON THE

GROUNDS THAT A DISEASE, ETC, NOT SPECIFICALLY EXCLUDED , HAS EXISTED

PRIOR TO THE EFFECTIVE DATE OF COVERAGE OF THIS POLICY

Acceptance - ANSInsurer's Underwriter approves and issues the policy

ACCIDENT - ONLY POLICIES - ANSACCIDENT - ONLY POLICIES

- COVERAGE FOR DEATH, DISMEMBERMENT OR DISABILITY, HOSPITAL OR

MEDICAL CARE RESULTING IN AN ACCIDENT

ACCIDENTAL BODILY INJURY - ANSUNINTENDED ACCIDENT

ACTIVE PARTICIPANT - ANSMEMBER IN GOOD STANDING; ASSOCIATION WHO

ATTENDS 4 OR MORE HOURS OF ASSOCIATION MEETINGS

AD & D - ANSAD & D CAN BE WRITTEN AS A RIDER OR A SEPARATE POLICY

PAYS A LUMP SUM BENEFIT IN THE EVENT OF DEATH FROM AN ACCIDENT AS

DEFINED IN THE POLICY OR THE LOSS OF BDY PARTS CAUSED BY A ACCIDENT

PRINCIPLE SUM IS PAID FOR ACCIDENTAL DEATH

CAPITAL SUM IS PAID FOR AS A PERCENTAGE OF THE PRINCIPLE SUM IN THE CASE

OF LOSS OF EYESIGHT OR ACCIDENTAL DISMEMBERMENT

THE POLICY WILL PAY FULL PRINCIPLE FOR LOSS OF SIGHT IN BOTH EYES OR TWO

OR ORE LIMBS

*****NOTE: SOME POLICIES WILL PAY DOUBLE OR TRIPLE THE FACE AMOUNT

(INDEMNITY) IN THE EVENT OF ACCIDENTAL DEATH

*****NOTE: POLICIES MUST PAY THE ACCIDENTAL DEATH BENEFIT OF DEATH

CAUSED BY AN ACCIDENT AND OCCURS WITHIN 90 DAYS

Adhesion - ANSContract is prepared by one of the parties (insurer) and accepted or rejected by the insured on a Take -it -or-Leave it bases by the insurer ADJUSTER - ANSANYONE EXCEPT AN ATTORNEY WHO FILES A CLAIM FOR THE INSURED ADULT DAY CARE - ANSADULT DAY CARE IDS PROVIDED FOR FUNCTIONALLY IMPAIRED ADULTS ON LESS THAT A 24 HOUR BASIS AT A NEIGHBORHOOD RECREATION CENTER AFFORDABLE CARE ACT - ACA - ANSPATIENT PROTECTION & AFFORDABLE CARE ACT

PPACA OR ACT

SIGNED INTO LAW MARCH 23, 2010

MANDATED INCREASED PREVENTATIVE, EDUCATIONAL, AND COMMUNITY BASED

SERVICES TO ASSIST LOWER COSTS OF HEALTH INSURANCE

AFFORDABLE CARE ACT - PURPOSE - ANSSET UP A NEW PRIVATE HEALTH

INSURANCE MARKET

KEEP PREMIUMS LOW

PREVENTS DENIALS, AND ALLOWS PERSONS WITH PRE-EXISTING CONDITIONS TO

OBTAIN INSURANCE

STABILIZES BUDGET & ECONOMY, REDUCING GOVERNMENT OVERSPENDING

EXTENDS COVERS TIL AGE 26

NOTE: LTC PLANS ARE EXEPMT TO PPACA CHANGES

AGENT - ANS- TERM AGENT INCLUDES: PRODUCER, DOES NOT INCLUDE A

CUSTOMER REPRESENTATIVE

Agreement - ANSAcceptance & Offer Aleatory - ANSAn ex amounts or exchange of unequal amounts or values AMBULATORY SURGICAL SERVICES - ANSCARE PROVIDED AT AN AMBULATORY CENTER THAT DOES NOT REQUIRE A HOSPITAL STAY AN INSURANCE EXCHANGES HELPS AN APPLICANT TO - ANSCOMPARE PRIVATE HEALTH PLANS HEALTH CARE OPTIONS IN CHOOSING COVERAGE OBTAIN INFO ON ELIGIBLE TAX CREDITS FOR THE MOST AFFORDABLE COVERAGE ENROLL IN PLAN THAT MEETS INDIVIDUAL NEEDS

ANNUAL BENEFIT - ANSANNUAL BENEFIT IS THE MAX A POLICY WILL PAY EACH

YEAR

ANNUAL DEDUCTIBLE/CALENDAR YEAR DEDUCTIBLE - ANSANNUAL/CALENDAR

YEAR DEDUCTIBLE IS PAID OUT ONCE PER YEAR

APPOINTMENT - - ANSAN AUTHORITY GIVE BY AN INSURANCE COMPANY TO AN

EMPLOYER TO A LICENSEE TO TRANSACT INSURANCE OR ADJUST CLAIMS FOR THE

INSURANCE COMPANY OR EMPLOYER

APPROVED AMOUNT - ANSAMOUNT MEDICARE DETERMINES TO BE REASONABLE

UNDER MEDICARE PART B

ASSIGNMENT - ANSPHYSICIAN OR SUPPLIER AGREES TO ACCEPT THE MEDICARE

APPROVED AMOUNT FOR THE SERVICES

ASSOCIATION - - ANSFAIA - FLORIDA ASSOCIATION OF INSURANCE AGENTS OR

OTHER ASSOCIATIONS - FAIFA, FAHU, LAAIA, FAPIA, FBAA, PBUS

Attending Physician's Report - ANSTHE UNDERWRITER may deem it necessary to obtain an attending physician's statement (APS) and forward it to the physician to

be completed. This statement will reveal exactly what the applicant was treated for, the treatment required, the length of treatment and the prognosis BASIC HOSPITAL COVERAGE - ANSCOVERS ROOM & BOARD BASIC HOSPITAL,SURGICAL, MEDICAL SUPPLIES AND MAJOR MEDICAL - ANSMEDICAL EXPENSE INSURANCE BASIC MEDICAL EXPENSE COVERAGE (BASIC PHYSICIAN"S NON-SURGICAL EXPENSE) - ANSNON SURGICAL SERVICES PROVIDED BY PHYSICIANS BASIC SURGICAL EXPENSE COVERAGE (WRITTEN IN CONJUNCTION WITH HOSPITAL EXPENSE POLICY) - ANSPAYS THE COSTS OF SURGEONS SERVICES (INCLUDES FESS, ANESTHESIOLOGIST, OPERATING ROOM) BASIC SURGICAL EXPENSE COVERAGE - CONTINUED - ANSUNDER BASIC SURGICAL EXPENSE, EACH CONTRACT HAS A "SURGICAL SCHEDULE" WHICH LIST TYPES OF OPERATIONS COVERED AND THEIR ASSIGNED DOLLAR AMOUNTS. IF OPERATION IS NOT LISTED, CONTRACT MAY PAY FOR A COMPARABLE OPERATION.

BENEFIT LIMITATIONS - ANSBENEFIT LIMITATIONS IS THE AMOUNT OF MONTHLY

BENEFIT THAT IS BASED ON THE PERCENTAGE OF THE INSURED'S PAST EARNINGS

BENEFIT IS CALCULATED ON 66% OF EARNINGS

BENEFIT PERIOD - ANSBENEFIT PERIOD IS THE LENGTH OF TIME IN WHICH THE

MONTHLY DISABILITY PAYMENT WILL LAST

CAFETERIA PLAN - ANSCHOICE OF DIFFERENT TYPES OF BENEFITS

CANCELLABLE - ANSTHE CANCELLABLE PROVISION ALLOWS THE INSURER TO

CANCEL THE POLICY AT ANY TIME, OR AT THE END OF THE POLICY PERIOD.

THE INSURER MUST PROVIDE PROPER WRITTEN NOTICE OF THE CANCELLATION

AND A REFUND OF ANY UNEARNED PREMIUM MADE.

CANCELLATION - ANSTERMINATION BY EITHER INSURED OR INSURER PRIOR TO

EXPIRATION DATE

CANCER POLICIES - ANSCANCER POLICIES

- COVERS ONLY CANCER

- PAYS A LUMP-SUM WHEN THE INSURED IS FIRST DIAGNOSED WITH CANCER

- SUPPLEMENTAL DESIGNED TO FILL THE GAP OF INSURED'S TRADITIONAL HEALTH

COVERAGE

CARRIERS - ANSORGANIZATIONS THAT PROCESS CLAIMS SUBMITTED BY

DOCTORS/SUPPLIERS UNDER MEDICARE

CARRY - OVER PROVISION - ANSCARRY - OVER PROVISION

IF THE INSURED DID NOT INCUR ENOUGH EXPENSES DURING THE YEAR TO MEET

THE ANNUAL DEDUCTIBLE, ANY EXPENSES INCURRED DURING THE LAST 3

MONTHS MY BE CARRIED OVER TO THE NEXT POLICY YEAR

CHANGE OF BENEFICIARY - ANSNOTE: IF A POLICY PROVIDES A DEATH BENEFIT, IT

MUST ALSO INCLUDE A CHANGE OF BENEFICIARY PROVISION

CHANGE OF BENEFICIARY - ANSPOLICY OWNER MAY CHANGE BENEFICIARY AT

ANYTIME, UNLESS THE BENEFICIARY IS IRREVOCABLE

CHANGE OF OCCUPATION - ANSBECAUSE THE OCCUPATION OF THE INSURED IS

IMPORTANT TO UNDER WRITING,

A "PROVISION" IS ALLOWED THE INSURER TO "ADJUST BENEFITS IF THE INSURED

CHANGES OCCUPATIONS."

Changes in the Application - ANSBest to start the application over. If not practical, draw a line through the incorrect info, insert the correct info and have the APPLICANT INITIAL THE CORRECT ANSWER. CLAIMS "FACILITY OF PAYMENT CLAUSE" - ANSINSURER'S RIGHT TO EXPEDITE A SPECIFIED LIMIT IN BENEFITS TO A RELATIVE OR INDIVIDUAL WHO IS EQUITABLY ENTITLED TO PAYMENT CLAIMS PROCEDURES - ANS1) NOTICE OF CLAIM - INSURED'S DUTY TO NOTIFY TO INSURER WITHIN 20 DAYS OF A LOSE

2) UPON NOTIFICATION, THE INSURER MUST SUPPLY CLAIMS FORMS, USUALLY

WITHIN 15 DAYS

IMPORTANT: IF FORMS ARE NOT RECEIVED BY THE CLAIMANT, THE CLAIMANT IS

DEEMED TO HAVE COMPLIED WITH THE REQUIREMENTS, IF THEY SUBMIT

WRITTEN PROOF OF THE LOSS TO THE INSURER.

CLAIMS TERMINOLOGY - ANSTHERE ARE APPROXIMATELY 18 TERMS

CO PAYMENTS - ANSTHIS PROVISION HAS A "SET DOLLAR" AMOUNT THE INSURED

PAYS EACH TIME CERTAIN MEDICAL SERVICES ARE USED

CO-INSURANCE - ANSMAJOR MEDICAL POLICIES INCLUDE "CO-INSURANCE"

PROVISION

AFTER INSURED SATISFIES THE DEDUCTIBLE, THE INSURER PAYS THE MAJORITY OF

EXPENSES

TYPICALLY 80/20, 90/10, 75/25, 50/

COBRA - ANSCOBRA CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT

QUALIFYING EVENTS:

- VOLUNTARY TERMINATION

- TERMINATION OF EMPLOYMENT OTHER THAT GROSS MISCONDUCT

- COMPANY DOWNSIZING

- EMPLOYMENT STATUS CHANGE FROM FULL TIME TO PART TIME

COVERAGE FOR THE ABOVE EVENTS ARE FOR "18 MONTHS."

FOR EVENTS SUCH AS:

-DEATH, DIVORCE AND LEGAL SEPARATION, TIME IS EXTENDED TO 36 MONTHS

COINSURANCE - ANSPORTION OF MEDICARE'S APPROVED AMOUNT THAT THE

BENEFICIARY IF TO PAY

COMMON ACCIDENT PROVISION - ANSCOMMON ACCIDENT PROVISION

MORE THAN ONE MEMBER IS INJURED IN A SINGLE ACCIDENT

ONLY ONE DEDUCTIBLE APPLIES TO THE ALL MEMBERS INVOLVED

Competent Parties - ANSParties must be capable, legal age, mentally competent, free of alcohol and drugs Completeness & Accuracy - ANSIt is the Agent's responsibility to make certain the application is filled out completely, and to the best of the applicant's knowledge COMPREHENSIVE COVERAGE - ANSCOVERS MOST MEDICAL EXPENSES COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SERVICES - ANSOUTPATIENT SERVICES RECEIVED BY A OUTPATIENT REHABILITATION FACILITY MEDICARE PARTICIPATING COMPREHENSIVE Conditional - ANSThe requirement that certain conditions must be met by the insured and the insurer in order for a contract to executed, and before each party fulfills it's obligations Consideration - ANSInsured pays the premium and the representations made in the app and the Insurer promise to pay in the event of a loss

CONSIDERATION CLAUSE - ANSAGAIN USUALLY ON THE FIRST PAGE

BOTH PARTIES OF THE CONTRACT GIVE VALUE CONSIDERATION

INSURED - PAYS THE PREMIUM AND FULFILLS HIS/HER STATEMENTS IN THE

CONTRACT

INSURER - PROMISES TO PAY IN THE EVENT OF A LOSS

CONSUMER REPORTS - ANSWRITTEN/ORAL INFO REGARDING A CONSUMER'S

CREDIT, CHARACTER, REPUTATION, OR HABITS COLLECTED BY A REPORTING

AGENCY FROM EMPLOYMENT RECORDS, CREDIT REPORTS, AND OTHER PUBLIC

SOURCES.

CONTINGENT OR SECONDARY BENEFICIARY - ANSUPON PRIMARY BENEFICIARY'S

DEATH, BENEFITS WILL BE PAYABLE TO THE CONTINGENT OR SECONDARY

Contract Law - ANSElements of a Contract

COORDINATION OF BENEFITS - COB - ANSCOB ESTABLISHES WHICH IS THE

"PRIMARY" PLAN OR THE PLAN THAT WILL PAY FULL BENEFITS AS IT SPECIFIES

ONCE THE PRIMARY PLAN HAS PAID, THE INSURER WILL SUBMIT A CLAIM TO THE

"SECONDARY" PROVIDER

CORRIDOR DEDUCTIBLE - ANSWHAT IS CALLED THE AMOUNT AN INSURER MUST

PAY BEFORE MAJOR MEDICAL COVERAGE WILL PAY.

COVERAGE FOR DEPENDENTS UP TO 26 - ANSAFFORDABLE CARE ACT MANDATES

COVERAGE FOR CHILDREN UP TO "26" REGARDLESS OF MARITAL STATUS,

RESIDENCY, FINANCIAL INDEPENDENCE ON THEIR PARENTS, OR ELIGIBILITY TO

ENROLL IN EMPLOYER'S PLAN

COVERED SERVICES - INPATIENT HOSPITAL CARE - ANSSEMI-PRIVATE ROOM,

MEALS, REGULAR NURSING SERVICES, OPERATING AND RECOVERY COSTS, COST

FOR ANESTHESIA, INTENSIVE CARE, ETC

CRITICAL ILLNESS OR SPECIFIED DISEASE - ANSCRITICAL ILLNESS OR SPECIFIED

DISEASE

- COVERS MULTIPLE ILLNESSES

(HEART ATTACKS, STROKE, RENAL FAILURE

- LUMP-SUM IS ISSUED TO THE INSURED UPON DIAGNOSIS AND SURVIVAL OF ANY

ILLNESS COVERED BY THE POLICY

CUSTOMER REPRESENTATIVE - ANSAPPOINTED BY A GENERAL LONE AGENT OR

AGENCY TO ASSIST IN TRANSACTING THE BUSINESS OF INSURANCE

DEDUCTIBLE - ANSAMOUNT TE BENEFICIARY MUST PAY BEFORE MEDICARE PAYS

DEDUCTIBLE - ANSDOLLAR AMOUNT THAT MUST BE PAID BY INSURED BEFORE

COMPNAY WILL PAY OUT BENEFITS

DEDUCTIBLES - ANSDEDUCTIBLES IS A SPECIFIED DOLLAR AMOUNT THE INSURED

PAYS, PRIOR TO THE INSURER PAYING FOR BENEFITS

DENTAL EXPENSES - ANSDENTAL EXPENSES

- MAY BE PACKAGED OR INTEGRATED WITH OTHER HEALTH INSURANCE

- PEDIATRIC DENTAL COVERAGE IS AN ESSENTIAL BENEFIT UNDER THE

AFFORDABLE CARE ACT THAT "MUST BE AVAILABLE" AS PART OF A HEALTH LAN

OR AS A STAND ALONE PLAN FOR CHILDREN "18 OR YOUNGER,"

DISABILITY - ANSTHE INABILITY TO ENGAGE IN ANY GAINFUL WORK THAT EXISTS

IN THE NATIONAL ECONOMY

THE DISABILITY MUST RESULT FROM A PHYSICAL OR MENTAL IMPAIRMENT THAT

IS EXCEPTED TO RESULT IN EARLY DEATH, OR HAS LASTED OR IS EXPECTED TO LAST

FOR A CONTINUOUS PERIOD OF 12 MONTHS

DISABILITY - QUALIFICATION - ANSPERSON MUST HAVE EARNED A CERTAIN

AMOUNT OF CREDITS

A MAX OF 4 WORK CREDITS CAN BE EARNED EACH YEAR

GENERALLY, AN INDIVIDUAL NEEDS 40 CREDITS, 20 OF WHICH HAS BEEN EARNED

IN THE LAST 10 YEARS BEFORE THE DISABILITY

IN OTHER CIRCUMSTANCES THE AMOUNT OF CREDITS VARIES BY AGE

DISABILITY DETERMINATION SERVICES (DDS) - ANSAN AGENCY WHICH EVALUATES

PERSONS THAT APPLY FOR DISABILITY BENEFITS

DISABILITY WAITING PERIOD - ANS5 MONTHS UNDER SOCIAL SECURITY BEFORE

ANY BENEFITS WILL BE PAID

ACTUAL BENEFIT PAYMENTS START WITH THE 6 MONTH OF DISABILITY

DISABILITY- RECURRENT - ANSRECURRENT DISABILITY IS EXPRESSED IN A POLICY

USUALLY 3-6 MONTHS, DURING WHICH THE RECURRENCE OF AN ILLNESS OR

INJURY WILL BE CONSIDERED AS A CONTINUATION OF A PRIOR PERIOD OF

DISABILITY.

THE RECURRENT EVENT WILL NOT BE CONSIDERED TO BE A NEW PERIOD OF

DISABILITY SO THAT THE INSURED IS NOT SUBJECT TO ANOTHER ELIMINATION

PERIOD

DURABLE MEDICAL EQUIPMENT - ANSEQUIPMENT DEEMED MEDICAL NECESSARY

THAT THE DOCTOR PRESCRIPTS FOR USE IN THE HOME

ELIGIBLE EXPENSES - ANSELIGIBLE EXPENSES ARE EXPENSE THAT ARE COVER

UNDER A HEALTH INSURANCE PLAN

ELIMINATION PERIOD - ANSA TYPE OF DEDUCTIBLE COMMONLY FOUND IN

DISABILITY INCOME POLICIES

PERIOD OF DAYS FROM THE ONSET OF A DISABILITY TO THE COMMENCEMENT OF

BENEFITS TO BE PAID

ELIMINATION PERIOD - ANSELIMINATION PERIOD IS A WAITING PERIOD FROM

THE ONSET OF DISABILITY UNTIL BENEFIT PAYMENTS COMMENCE.

ELIMINATION PERIOD ID GENERALLY 30-180 DAYS

EMPLOYER NOTIFICATION RESPONSIBILITIES - ANSEMPLOYERS WHO OFFER

HEALTH INSURANCE ARE "REQUIRED" TO PROVIDE INFORMATION ABOUT THE

PPACA & ACA AND THE NEW HEALTH INSURANCE MARKETPLACE EXCHANGES

THE PURPOSE IS TO HELP EMPLOYEES EVALUATE HEALTH INSURANCE OPTIONS

ENROLLEE - ANSTHE INSURED - DOESN'T INCLUDE DEPENDENTS

Entire Contract - ANSAn issued policy that has a copy of the original application attached to the back of the policy ESSENTIAL BENEFITS OF ALL HEALTH PLANS OF THE MARKET PLACE - ANSGUARANTEED ISSUE - INDIVIDUAL OR GROUP GUARANTEE RENEWABILITY - INDIVIDUAL OR GROUP PRE-EXISTING CONDITIONS - COVER FOR INDIVIDUALS WHO HAVE BEEN DENIED BY PRIVATE INSURANCE COMPANIES APPEAL RIGHTS THE INSURER MUST PROVIDE "30" DAYS TO THE INSURED TO APPEAL IF REJECTED COVERAGE FOR CHILDREN - EXTENDED TO AGE 26 LIFETIME & ANNUAL BENEFITS - HEALTH PLANS ARE RESTRICTED FROM APPLYING DOLLAR LIMITS ON ESSENTIAL BENEFITS, NOR CAN THEY ESTABLISH A DOLLAR LIMIT ON THE AMOUNT OF BENEFITS PAID

EXCESS CHARGE - ANSTHE DIFFERENCE BETWEEN THE MEDICARE APPROVED

AMOUNT AND THE ACTUAL CHARGE

EXCHANGES - ANS2014 EACH STATE HAS BEEN REQUIRED TO SET UP EXCHANGES,

REFERRED TO AS MARKETPLACES

STATES THAT HAVE CHOSEN NOT TO SET BUILD UP THEIR OWN MARKET PLACE, A

FEDERALLY - FACILITATED MARKETPLACE IS SET UP KNOWN AS "HEALTHCARE.GOV.

EXCLUSIONS & LIMITATIONS - ANSEXCLUSIONS

SPECIFY WHAT THE INSURER WILL NOT PAY, MOST COMMON EXCLUSIONS ARE:

WAR, MILITARY SERVICE, SELF-INFLICTED INJURY, DENTAL EXPENSE, COSMETIC

EXPENSES, EYE REFRACTIONS, OR CARE IN GOVERNMENT FACILITIES

Explaining Sources of Insurability & HIPPA Priacy - ANSTo determine insurability of ,the applicant, the INSURER may use several sources MEDICAL INFORMATION BUREAU (MIB), REPORT for gathering underwriting info. the APPLICANT MUST BE ADVISED OF THE SOURCES BEING USED AND HOW THE INFO WILL BE USED. ALL SOURCES USED MUST ADHERE TO THE FAIR CREDIT REPORTING ACT.

EXPLANATION OF PROVISIONS, RIDERS, EXCLUSIONS AND RATINGS - ANSAGENT

MUST PROVIDE THE INSURED WITH AN EXPLANATION OF POLICY PRINCIPLES AMD

PROVISIONS. IF THERE ARE CHANGES MADE BY THE INSURER TO THE POLICY. THE

AGENT MUST EXPLAIN THE CHANGES AND OBTAIN A SIGNATURE FROM THE

INSURED ACKNOWLEDGING RECEIPT OF THESE AMENDMENTS.

FAIR CREDIT REPORTING ACT - ANSPROCEDURES THAT CONSUMER-REPORTING

AGENCIES MUST FOLLOW TO ENSURE RECORDS ARE CONFIDENTIAL, ACCURATE,

RELEVANT, AND PROPERLY USED.

THE LAW ALSO PROTECTS CONSUMERS AGAINST CIRCULATION OF INACCURATE

OR OBSOLETE PERSONAL OR FINANCIAL INFORMATION.

FAMILY DEDUCTIBLE - ANSFAMILY DEDUCTIBLE IS AN ANNUAL DEDUCTIBLE THAT

EACH FAMILY NEEDS TO SATISFY BEFORE THE INSURER PAYS BENEFITS

FIELD UNDERWRITING PROCEDURES - ANSAGENT/PRODUCER

fLEXIBLE SPENDING ACCOUNTS (FSAs) - ANSFSA IS A FORM OF CAFETERIA PLA FUNDED BY SALARY REDUCTION AND EMPLOYER CONTRIBUTIONS