Florida HEALTH insurance Laws and rules Flashcards
On the insurance application, the Insurer’s name must be displayed where, along with __?
must be displayed on the 1st page of the application form, ALONG with the agent’s name and license #
An individual or family accident and health insurance policy CANNOT be issued or delivered in Florida unless it has ____ delivered with it?
OUTLINE OF COVERAGE
Before an insurer can issue a health insurance policy in Florida, it must file its rating manual and rating schedule (premium rates) with ____ for approval?
The Office
How often must an insurer submit a filing to the Office to show the reasonableness of benefits in relation to premium rates?
Each year
Can an insurer refuse to issue a policy, or charge a higher premium solely because a person has sickle-cell trait?
NO
TRUE OR FALSE:
An insurer can refuse to issue a policy or charger a higher premium based on a person’s sex or marital status.
FALSE-the insurer CANNOT refuse b/c of sex or marital status
An insurer may not refuse coverage or cancel a policy because an insured has a fibrocystic condition, UNLESS ____?
UNLESS the condition is diagnosed through a breast biopsy that demonstrates an increased likelihood of developing breast cancer.
An insurer CANNOT exclude coverage for bone marrow transplants recommended by a physician, as long as the procedure is not considered ____?
experimental
What does the “Right to examine” (Free Look) period mean?
The policy holder has at least 10 days to review the policy after its been delivered.
If a Policy holder is unsatisfied with the policy for any reason, before the “Free-Look” period is up, they can do what?
Return the policy and get a full refund of the premium paid.
A Medicare supplement policy’s “free-look” period is different in what way?
They have 30 days to review and return the policy for a full refund, if unsatisfied.
To protect a LTC insurance policy from unintentionally lapsing, LTC applicants may do what?
They may designate another person to receive notice of lapse or termination due to nonpayment of premium.
If an insured doesn’t want another person to receive notice of lapse of their LTC policy, what may they do?
They may sign a waiver electing not to designate another person to receive a notice of lapse.
An insurer may terminate a LTC policy for non payment of premium, only after giving the insured and his/her designee at least how many days notice?
30 days
If a LTC policy is cancelled due to non payment of premium, the insured can have the policy reinstated if its within 5 months after the cancelation, AND ____?
- The insured or designee shows that failure to pay premium was unintentional and due to the insured’s cognitive impairment
2.loss of functional capacity - continuous confinement in a hospital,nursing or assisted living facility for more than 60 days.
Changes to an application for a health insurance policy are invalid UNLESS?
They are signed and approved by the APPLICANT
What is the purpose of the “Florida health insurance plan”?
It makes health insurance available to Florida residents who are denied coverage in the regular insurance market by AT LEAST 2 insurers b/c of prior medical conditions.
Changes to a health insurance CONTRACT can only be made by ____?
An officer of the insurance company.
What is the difference between the insurance contract and insurance application, in regards to making changes.
Contract=only officer can make changes
Application=only applicant/insured can make changes
A health insurance policy becomes incontestable on the basis of statements made in the application after how long? Unless the misstatements were made with the intent to defraud the insurer.
2 years
A policyholder is entitled to a grace period of ___, ___, or ___ days in which to pay the premium due?
7, 10, or 31 days
Does a policy still remain in force (active) during the grace period?
yes
What are the required terms for policies to have an additional 21 day grace period before lapse due to nonpayment of premium?
age 64 or older
policy in force for at least one year
written notice of a claim is due to the insurer within __ days of the loss?
20 days
After receiving notice of a claim, the insurer must provide the insured with forms to file for PROOF of the loss, within ___ days?
15 days
The insured must file PROOF of loss to the insurer within one year after it is required, UNLESS ___?
The claimant (insured) is legally incapacitated.
TRUE OR FALSE:
The insurer can require a physical examination of the insured whenever necessary to investigate a claim.
TRUE
By giving written notice to the insurer, the insured retains the right to change their beneficiary, UNLESS __?
Unless the insured makes an irrevocable beneficiary designation
If the insured’s age or sex was misstated in the application, benefits will be adjusted how?
they will be adjusted to what the premiums would have purchased at the correct age or sex.
Are individual and group health insurance policies required to provide benefits for maternity care?
No, but if they do, they must meet minimum standards must be met.
If a policy does cover maternity care, it must provide coverage for ___, and ___?
coverage for birth centers/ midwives and post-delivery care to the mother and newborn
Bill filed written proof of loss on April 1. Not having received a response by May 1, he decides to take legal action. His attorney will probably advise him to wait. How come?
The legal actions provision prohibits the insured from suing the insurer on a claim before 60 days have passed since filling the written proof of loss.
What circumstance can coverage be continued for a child beyond the limiting age specified in the policy?
If they are mentally or physically incapacitated.
Is an individual health insurance policy renewed automatically?
No- its renewed at the insured’s request
Insurers must give group policyholder’s the option of adding coverage for the treatment of ___ and ___?
Alcoholism and substance abuse.
Individual and Group policies are required to cover treatment provided in an ambulatory surgical center, IF ___?
If the treatment would have been covered on an inpatient basis.
Individual and group health policies must provide coverage for diagnostic and surgical procedures involving the bones or joints of the jaw and face, IF ___?
If medically necessary to treat congenital or developmental deformity, disease, or injury.
Individual and group health insurance policies must provide coverage for equipment, supplies, and outpatient self-management training and educational services that are medically necessary to treat ____?
diabetes
If a health insurance policy provides coverage for mastectomies, it must also provide coverage for ___ and ___?
prosthetic devices and reconstructive surgery
A health insurance policy that covers children under the age of ___ must provide coverage for cleft lip and cleft palate.
under age of 18
Are individual and group health insurance policies required to provide coverage for alcoholism and drug addiction?
No- They have the option to provide coverage, but its not required.
A health insurance policy can exclude treatment in a federal government facility, UNLESS __?
Unless coverage is required by law
Under HIPPA, a person with ___ months of creditable coverage MUST be given access to an insurance policy.
18 months.
What is considered “creditable coverage”?
A group health plan (insurance or HMO), individual policy, Medicare, Medicaid, or other government plan.
A group policy that provides mental health benefits must offer the same lifetime annual dollar limitations on benefits as for what other benefits (2) under the same policy?
medical and surgical benefits
Under HIPPA, pre-existing conditions are those for which medical advice or treatment was received or recommended up to ____ months before the effective date of coverage.
6 months
Under HIPPA, an insurer must cover pre-existing conditions no later than ___months after the effective date of coverage.
12 months
Under HIPPA, a group health insurer must allow employees and their dependents to enroll under a group policy if they previously declined enrollment because they ____?
previously had health insurance coverage.
When marketing Medicare Supplement plans in Florida, an insurer must display what on the first page of every policy?
display a “Notice to Buyer: this policy may not cover all of your medical expenses”.
The issuer of a Medicare supplement policy that replaces another, must waive any ___, ___, ___, and ___ in the policy to the extent these were satisfied under the original policy.
must waive- pre-existing condition periods, probationary periods, waiting periods, and elimination periods
HMO’s provide service through one of three models of operation. What are they?
- Group practice model
- Staff model
3.IPA-Independent practice association model
In Which type of HMO Model of operation does a group of physicians of varying specialties practice in one facility?
Group Practice model
If the medical group only provides services to HMO members, it is considered a ___ panel group.
closed
What type of HMO panel group has physicians that are salaried employees of the HMO and work at a clinic owned by the HMO?
Closed panel
In this HMO Model, physicians are DIRECT employees of the HMO and may ONLY see HMO patients.
Staff Model HMO
This HMO model is a network of individual physicians who contract with an HMO to provide health-care services. The physicians are located throughout a geographic area and operate independently of each other.
Independent practice association model
To operate as an HMO in Florida, an HMO must obtain a certificate of authority from who?
The Office of insurance regulation
HMO’s must file an annual report with the Office within __ months of each ___ ?
within 3 months of each fiscal year.
The Office must examine an HMO’s affairs, transactions, records, and assets AT LEAST ___ every ___ years.
AT LEAST once every 5 years
What is the grace period timeframe for which the group policyholder or individual subscriber can pay the premium? Does the policy remain in force during the grace period?
HMO= 10 day grace period.
Yes policy stays in force during grace period
If a person loses group coverage under an HMO contract for any reason, he/she is entitled to have an individual contract issued without evidence of insurability, IF the individual was covered by the group plan for at least _____ months before the coverage was terminated.
individual had to be covered for at least 3 months
HMO’s that offer group contracts in Florida must hold at least one ___ day open enrollment period every ___ months.
one 30 day open enrollment period every 18 months
What is it called when an HMO pays a fixed amount to a health-care provider under a contract? In exchange, the provider provides medical care for the HMO’s subscribers.
Capitation
HMO’s MUST provide coverage for ____ received outside of the HMO’s service area?
Must cover emergency care
Does an HMO need a license of certification to operate in Florida?
NO- HMO needs a Certificate of authority
An EPO (Exclusive provider organization) contracts with a very limited number of physicians and typically ____ hospital(s) to provide services to members.
typically one hospital to provide services
What is the name of the document that must be issued by a GROUP policy holder to each insured individual?
Certificate of insurance
Group health insurance policies must ____ for an insured who is totally disabled when the contract is discontinued?
must extend benefits for totally disabled
Medical discount plans do not pay for a person’s health insurance.
Instead, they require members to pay a fee for _____?
A list of health care providers who are willing to offer discounts to members of that plan.
HMO’s and EPO’s that offer dermatological services must cover ___, ____, and ___.
Office visits, procedures, and testing by dermatologists.
Does Florida require a minimum number of employees to be eligible for group health insurance?
NO
What plan/organization is prepaid by enrollees, and in return, provides the enrollees with access to limited health care services through an exclusive panel of providers?
Prepaid limited health service organization (PLHSO)
What is the purpose of the Florida Health Care Access Act?
promotes the availability of health insurance for small employers, regardless of claims experience or employees’ health status.
A small employer in Florida, for purposes of group health insurance, is defined as ___?
Any person or entity engages in business that employed between 1 and 50 employees during the previous year, and the majority of whom worked in Florida.
As a condition of transacting insurance in Florida, a small employer insurer MUST offer a ___ and a ___ health benefit plan.
basic and a standard
The Small Employers Access Program expands affordable health insurance coverage options for small employers through what method?
purchasing pools
The Florida Healthy Kids corporation offers comprehensive insurance and health care for uninsured children ages ____ through ___ in the state.
ages 5-18
Cover Florida Health Care guarantees affordable health-care coverage to Florida residents ages 19-64 who have been uninsured for at least ___?
6 months
