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Florida Health Insurance > Florida HEALTH insurance Laws and rules > Flashcards

Florida HEALTH insurance Laws and rules Flashcards

1
Q

On the insurance application, the Insurer’s name must be displayed where, along with __?

A

must be displayed on the 1st page of the application form, ALONG with the agent’s name and license #

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2
Q

An individual or family accident and health insurance policy CANNOT be issued or delivered in Florida unless it has ____ delivered with it?

A

OUTLINE OF COVERAGE

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3
Q

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?

A

The Office

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4
Q

How often must an insurer submit a filing to the Office to show the reasonableness of benefits in relation to premium rates?

A

Each year

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5
Q

Can an insurer refuse to issue a policy, or charge a higher premium solely because a person has sickle-cell trait?

A

NO

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6
Q

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.

A

FALSE-the insurer CANNOT refuse b/c of sex or marital status

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7
Q

An insurer may not refuse coverage or cancel a policy because an insured has a fibrocystic condition, UNLESS ____?

A

UNLESS the condition is diagnosed through a breast biopsy that demonstrates an increased likelihood of developing breast cancer.

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8
Q

An insurer CANNOT exclude coverage for bone marrow transplants recommended by a physician, as long as the procedure is not considered ____?

A

experimental

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9
Q

What does the “Right to examine” (Free Look) period mean?

A

The policy holder has at least 10 days to review the policy after its been delivered.

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10
Q

If a Policy holder is unsatisfied with the policy for any reason, before the “Free-Look” period is up, they can do what?

A

Return the policy and get a full refund of the premium paid.

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11
Q

A Medicare supplement policy’s “free-look” period is different in what way?

A

They have 30 days to review and return the policy for a full refund, if unsatisfied.

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12
Q

To protect a LTC insurance policy from unintentionally lapsing, LTC applicants may do what?

A

They may designate another person to receive notice of lapse or termination due to nonpayment of premium.

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13
Q

If an insured doesn’t want another person to receive notice of lapse of their LTC policy, what may they do?

A

They may sign a waiver electing not to designate another person to receive a notice of lapse.

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14
Q

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?

A

30 days

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15
Q

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 ____?

A
  1. 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
  2. continuous confinement in a hospital,nursing or assisted living facility for more than 60 days.
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16
Q

Changes to an application for a health insurance policy are invalid UNLESS?

A

They are signed and approved by the APPLICANT

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17
Q

What is the purpose of the “Florida health insurance plan”?

A

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.

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18
Q

Changes to a health insurance CONTRACT can only be made by ____?

A

An officer of the insurance company.

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19
Q

What is the difference between the insurance contract and insurance application, in regards to making changes.

A

Contract=only officer can make changes
Application=only applicant/insured can make changes

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20
Q

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.

A

2 years

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21
Q

A policyholder is entitled to a grace period of ___, ___, or ___ days in which to pay the premium due?

A

7, 10, or 31 days

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22
Q

Does a policy still remain in force (active) during the grace period?

A

yes

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23
Q

What are the required terms for policies to have an additional 21 day grace period before lapse due to nonpayment of premium?

A

age 64 or older
policy in force for at least one year

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24
Q

written notice of a claim is due to the insurer within __ days of the loss?

A

20 days

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25
Q

After receiving notice of a claim, the insurer must provide the insured with forms to file for PROOF of the loss, within ___ days?

A

15 days

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26
Q

The insured must file PROOF of loss to the insurer within one year after it is required, UNLESS ___?

A

The claimant (insured) is legally incapacitated.

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27
Q

TRUE OR FALSE:
The insurer can require a physical examination of the insured whenever necessary to investigate a claim.

A

TRUE

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28
Q

By giving written notice to the insurer, the insured retains the right to change their beneficiary, UNLESS __?

A

Unless the insured makes an irrevocable beneficiary designation

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29
Q

If the insured’s age or sex was misstated in the application, benefits will be adjusted how?

A

they will be adjusted to what the premiums would have purchased at the correct age or sex.

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30
Q

Are individual and group health insurance policies required to provide benefits for maternity care?

A

No, but if they do, they must meet minimum standards must be met.

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31
Q

If a policy does cover maternity care, it must provide coverage for ___, and ___?

A

coverage for birth centers/ midwives and post-delivery care to the mother and newborn

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32
Q

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?

A

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.

33
Q

What circumstance can coverage be continued for a child beyond the limiting age specified in the policy?

A

If they are mentally or physically incapacitated.

34
Q

Is an individual health insurance policy renewed automatically?

A

No- its renewed at the insured’s request

35
Q

Insurers must give group policyholder’s the option of adding coverage for the treatment of ___ and ___?

A

Alcoholism and substance abuse.

36
Q

Individual and Group policies are required to cover treatment provided in an ambulatory surgical center, IF ___?

A

If the treatment would have been covered on an inpatient basis.

37
Q

Individual and group health policies must provide coverage for diagnostic and surgical procedures involving the bones or joints of the jaw and face, IF ___?

A

If medically necessary to treat congenital or developmental deformity, disease, or injury.

38
Q

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 ____?

A

diabetes

39
Q

If a health insurance policy provides coverage for mastectomies, it must also provide coverage for ___ and ___?

A

prosthetic devices and reconstructive surgery

40
Q

A health insurance policy that covers children under the age of ___ must provide coverage for cleft lip and cleft palate.

A

under age of 18

41
Q

Are individual and group health insurance policies required to provide coverage for alcoholism and drug addiction?

A

No- They have the option to provide coverage, but its not required.

42
Q

A health insurance policy can exclude treatment in a federal government facility, UNLESS __?

A

Unless coverage is required by law

43
Q

Under HIPPA, a person with ___ months of creditable coverage MUST be given access to an insurance policy.

A

18 months.

44
Q

What is considered “creditable coverage”?

A

A group health plan (insurance or HMO), individual policy, Medicare, Medicaid, or other government plan.

45
Q

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?

A

medical and surgical benefits

46
Q

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.

A

6 months

47
Q

Under HIPPA, an insurer must cover pre-existing conditions no later than ___months after the effective date of coverage.

A

12 months

48
Q

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 ____?

A

previously had health insurance coverage.

49
Q

When marketing Medicare Supplement plans in Florida, an insurer must display what on the first page of every policy?

A

display a “Notice to Buyer: this policy may not cover all of your medical expenses”.

50
Q

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.

A

must waive- pre-existing condition periods, probationary periods, waiting periods, and elimination periods

51
Q

HMO’s provide service through one of three models of operation. What are they?

A
  1. Group practice model
  2. Staff model
    3.IPA-Independent practice association model
52
Q

In Which type of HMO Model of operation does a group of physicians of varying specialties practice in one facility?

A

Group Practice model

53
Q

If the medical group only provides services to HMO members, it is considered a ___ panel group.

A

closed

54
Q

What type of HMO panel group has physicians that are salaried employees of the HMO and work at a clinic owned by the HMO?

A

Closed panel

55
Q

In this HMO Model, physicians are DIRECT employees of the HMO and may ONLY see HMO patients.

A

Staff Model HMO

56
Q

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.

A

Independent practice association model

57
Q

To operate as an HMO in Florida, an HMO must obtain a certificate of authority from who?

A

The Office of insurance regulation

58
Q

HMO’s must file an annual report with the Office within __ months of each ___ ?

A

within 3 months of each fiscal year.

59
Q

The Office must examine an HMO’s affairs, transactions, records, and assets AT LEAST ___ every ___ years.

A

AT LEAST once every 5 years

60
Q

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?

A

HMO= 10 day grace period.
Yes policy stays in force during grace period

61
Q

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.

A

individual had to be covered for at least 3 months

62
Q

HMO’s that offer group contracts in Florida must hold at least one ___ day open enrollment period every ___ months.

A

one 30 day open enrollment period every 18 months

63
Q

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.

A

Capitation

64
Q

HMO’s MUST provide coverage for ____ received outside of the HMO’s service area?

A

Must cover emergency care

65
Q

Does an HMO need a license of certification to operate in Florida?

A

NO- HMO needs a Certificate of authority

66
Q

An EPO (Exclusive provider organization) contracts with a very limited number of physicians and typically ____ hospital(s) to provide services to members.

A

typically one hospital to provide services

67
Q

What is the name of the document that must be issued by a GROUP policy holder to each insured individual?

A

Certificate of insurance

68
Q

Group health insurance policies must ____ for an insured who is totally disabled when the contract is discontinued?

A

must extend benefits for totally disabled

69
Q

Medical discount plans do not pay for a person’s health insurance.
Instead, they require members to pay a fee for _____?

A

A list of health care providers who are willing to offer discounts to members of that plan.

70
Q

HMO’s and EPO’s that offer dermatological services must cover ___, ____, and ___.

A

Office visits, procedures, and testing by dermatologists.

71
Q

Does Florida require a minimum number of employees to be eligible for group health insurance?

A

NO

72
Q

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?

A

Prepaid limited health service organization (PLHSO)

73
Q

What is the purpose of the Florida Health Care Access Act?

A

promotes the availability of health insurance for small employers, regardless of claims experience or employees’ health status.

74
Q

A small employer in Florida, for purposes of group health insurance, is defined as ___?

A

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.

75
Q

As a condition of transacting insurance in Florida, a small employer insurer MUST offer a ___ and a ___ health benefit plan.

A

basic and a standard

76
Q

The Small Employers Access Program expands affordable health insurance coverage options for small employers through what method?

A

purchasing pools

77
Q

The Florida Healthy Kids corporation offers comprehensive insurance and health care for uninsured children ages ____ through ___ in the state.

A

ages 5-18

78
Q

Cover Florida Health Care guarantees affordable health-care coverage to Florida residents ages 19-64 who have been uninsured for at least ___?

A

6 months

Florida Health Insurance (14 decks)

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