____________ is knowingly making any misleading representations of any HMO contract for the purpose of inducing any person to contract or to purchase an insurance policy or HMO contract with an insurance company or HMO.

The Florida Health Maintenance Organization Consumer Assistance Plan provides coverage up to ___ months after an HMO liquidation.

An HMO contract, certificate, or member’s handbook must be delivered within __ working days after approval of the enrollment by the HMO.

Florida law requires HMOs to provide up to ___ office visits to a dermatologist without a referral from a primary care physician within a twelve month time period.

An HMO has ___ months after payment of a claim to submit a claim for overpayment to the provider; and a provider has ___ months after payment of a claim by an HMO to submit a claim for underpayment.

An HMO has up to ____ days after the receipt of a claim from a contact provider for services/goods to pay or deny the claim.

The HMOCAP was created by Florida statute to protect HMO plan subscribers against the failure of their HMO to perform its contractual obligations due to its insolvency. The maximum benefit to a subscriber is $_______________.

Which of the following are filing requirements of an HMO? (choose all that apply)

A __________ is the specified dollar amount that the HMO subscriber must pay for certain covered health care services.

Which of the following are “savings” associated with HMOs? (choose all that apply)

A ___________ is any physician, hospital, organization, or other person or institution that furnishes health care services and is licensed or otherwise authorized to practice in Florida.

This HMO provision ensures that claims approved and benefits started while the contract was in force will be paid.

The ________________ period is the period of time each year when an individual can sign up for health insurance coverage.

Florida Healthy Kids provides health insurance coverage to *uninsured* children in families with an income below 200% of the federal poverty level who do not qualify for _________.

_____ are characterized by negotiated fees for services; reduced benefits for out of service providers; and co-payments and deductibles.

“The Bean” coffee shop has ten employees and has purchased a stop-loss health insurance policy. “The Bean’s” owner, Crawford has projected her future claims will be around $14,000 (based on her prior years’ experience).

What is the attachment point for “The Bean’s” renewing stop loss policy?

An LTC policy may condition the payment of benefits on a determination of either the insured’s inability ability to perform up to ___ activities of daily living; or on cognitive impairment.

LTC insurers are required to offer inflation protection at a rate of not less than __% compounded annually.

_________ care is for the “basic activities of everyday living”; that is non-medical care which can be provided in various settings (e.g. at home, adult day care).

Long-Term Care normally refers to care of ___ days or longer.

True or False? Both Medicare and Medicare Supplements cover long term custodial and nursing home care.

ERISA’s ________ clause relegates to the states the regulation of insurance.

Which ‘rule’ determines whether a health insurance plan is primary or secondary for a dependent child covered by both parents’ benefit plans when the parents live together. The plan covering the parent whose birthday falls first in a calendar year provides primary coverage for the child.

The Florida Health Insurance Coverage Continuation Act extends health insurance to employees of small employers and dependents if COBRA benefits are not available up to ___ months.

Randall T’s doctor sent him a bill for a balance due which is an amount in addition to the agreed price already paid by his insurance company. What should Randall do?

Individual and group health insurance policies are required to provide coverage for mammograms how often for any woman 50 years or older?

Grandfathered Health plans must have had plans in effect on or before:

The insured has up to how many days after a policy is issued to return the policy and receive a full refund of any premium paid.

The purpose of the Florida Life and Health Insurance Guaranty Association’s (FLAHIGA) is to _________ the insuring public against the insolvency of an insurance company. By and large the Association provides benefits to Florida residents.

The department has rules regarding the inappropriate use of _____________ and ______________.

Micah wants to obtain his insurance license. How many times can he take an examination for a license type?

Applicants for an agent license must pass an examination that will test the applicant’s ability, competence, and ___________. The exam will cover the duties and responsibilities of a licensee and the pertinent provisions of Florida law.

Judith has failed to maintain an appointment with an insurer or an appointing entity during the last 48 months. Judith now has to qualify with the department as a first-time ___________.

While selling Mrs. Marge an insurance policy, Homer told her the insurance company had an A++ rating. Is Homer guilty of misrepresentation if he did not know the actual rating at that time?

Sorbo Health Insurance Company has gone out of business. FLAHIGA will pay for any one’s insured’s medical expenses. What is the maximum amount FLAHIGA will pay?

______________________ is the principal in which an agent is operating in the best interest of the business of life insurance.

True or False? By Statute, Insurance companies have twenty days to respond to the depart­ment once a consumer complaint has been filed.

Which, if any, of the following statements are correct regarding a license applicant background check?

Statement I. An application for an insurance license shall be subject to a criminal background check by the department.

Statement II. An application for an insurance license shall be subject to a credit background check by the department.

Grace is having her Kindness Insurance Company appointment terminated. What must Kindness do to put all parties of interest on notice of the termination?

J. Jones Insurance Agency received a $5,500 group insurance premium for a group insurance policy for one of the agency’s insureds and deposited those funds it is operating account. Thereafter, the agency used part of the premium as a “float” to pay a very large and very late credit card bill. What is the agency guilty of?

Marsha Marsha, a licensee, must notify the department, in writing, within __ days after a change of name, residence address, principal business street address, mailing address, contact telephone numbers, including a business telephone number, or email address.

Any person or entity that transacts insurance without a certificate of authority is guilty of at least a __________ felony.

Slade Markham is in a “one-man-band” where he is the owner, agent, and service department for his one personal health insurance agency, The Slade Markham Agency. Is Mr. Markham required to have an agency license?

Which of the following are the duties and powers of the department regarding FLAHIGA and the liquidation of insurance companies?

Rebating is always lawful.

True or False? No person other than a licensed and appointed agent may accept any commission or other valuable compensation for soliciting or negotiating insurance.

___ years of record retention are required by the department.

True or False? False advertising is knowingly making, publishing, disseminating, circulating, or placing before the public untrue, deceptive, or misleading information with respect to any business of insurance.

Mr. Rogers sold Misty a Health Insurance policy and was able to add an Accidental Death & Dismemberment policy for only $15 extra dollars a month. Misty asked if the AD&D was part of the Health policy and Mr. Rogers told her it was already included in the monthly premium she quoted her. Is Mr. Rogers guilty of sliding?

Cameron gave Kenisha Kent a $25 gift certificate to Kenisha’s favorite restaurant as part of his schomoozing to sell her company, All Kinds of Kupcakes, Inc., a pension plan. Is Cameron guilty of unfair practice?

Which of the following are benefits to an employer in providing “excellent” employer provided benefits?

All of the following are benefits of group insurance coverage EXCEPT?

Which, if any, of the following are correct statements regarding the tax implications of Business Overhead Expense Insurance?

Statement I. Business Overhead Expense Insurance are tax deductible as a business expense to the business.

Statement II. Benefits received from the business are taxable as income to the business.

How does key person disability insurance help a business?

A Cafeteria Plan is a plan governed by IRS Section 125 which allows employees to contribute a certain amount of their gross income for benefits before ______ are calculated.

Business continuation plans assist a business with continuity of its operations and employee ____________.

Which type of insurance would a business purchase for their exposure to a disabled owner but not for a disabled key person?

If OkayTire Shop decides to purchase key person disability insurance to offset any loss of income and increased expenses if, Kenny, the top salesman, were to become disabled. How much key person DI should Okay Tire purchase if:

Kenny’s Salary $110,000
Loss of income to the shop $90,000
Extra expense of new hire, training, loss of accounts $35,000

What are the tax implications if key person disability insurance (choose all that apply)?

Which of the following are HSA eligible qualified health care expenses?

Traci Gooding’s Group Accidental Death & Dismemberment policy pays $100,000 upon her accidental death and $50,000 for the accidental loss of a hand, arm, foot, or leg.

DI benefits coordinate with Workers Compensation benefits to the pay insured about __% of the insured’s income.

Michele obtains her health insurance coverage through her employer; her employer pays 50% of the cost of the insurance and Michele pays the other 50%.

Group plans are issued for employer and other group with the contract of coverage being held between the insurance company and the group. The group is issued a ___________ and individuals in the group are issued certificates of insurance which outline the plans benefits.

Which of the following groups WOULD NOT QUALIFY for a group health insurance policy?

True or False? To be eligible for group health coverage the group must be either a natural group; or an “unnatural group”, one which has been formed the sole purpose of obtaining group insurance.

Cynthia has purchased a new Tesla and she really, really likes it. Her best friend lost her car when the friend suffered an illness which left her without work for ten months.

What policy can Cynthia purchase to make sure the payments on her car loan are made in the event she is either unable to work due to an accident or any illness?

Jerry has filed to keep his group health insurance after terminating his employment (COBRA). The total cost of Jerry’s group health insurance was $1,000.

What is the maximum amount Jerry can be charged for his extended group coverage?

Caroline has been at the same part-time job for the four years she has been in college. Her employer just started a group health insurance plan and she was told she will not be eligible for the plan.

Caroline thought there was no underwriting for a group health insurance plan and has questioned the HR director at her place of employment.

True or False? Long-Term plans often use an “any occupation” definition for the first two years and an “own occupation” definition thereafter.

Group medical expense plans are required to offer __________ benefits for all plans which insure fifteen (15) or more people.

Florida law requires groups of ___ or more persons to be accepted as a whole or rejected as a whole for group health insurance plans.

Insurers have ___________ to protect the insurance company against adverse selection and to apportion the cost of plan administration among an adequate number of insureds.

AppleSnacks is a small, minority based business which makes apple fruit pies for sale on consignment. AppleSnacks has ten full time employees.

Does AppleSnacks have the minimum number of employees to be eligible for a group health insurance policy in Florida?

The Coordination of Benefits (COB) provision in group health plans is in place to remove the______________ hazards of “over-insurance”.

Ericka Little’s employment with the FunCoToy Company has ended. FunCoToy is moving their current distribution center to McLean, Virigina and Ericka cannot make the move due to her husband’s employment.

Ericka’s family has depended on the health insurance provided by FunCoToy.

True or False? The cost for a group plan health insurance is more expensive than individually underwritten health insurance.

Which of the following is an example of “adverse selection”?

All of the following are moral hazards affecting Health Insurance underwriting Except?

Which of the following are true regarding gender in Insurance underwriting?

Joannie is a truck driver, Alice is a sous chef, and Angie is a demolition expert using explosives in underground mining.

Which occupation would have the highest probability and severity of an occupation injury?

Janice is trying to keep her premiums as low as possible. Which of the following might Janice use to keep her premiums “low”?

___________ _____________ uses an insurer specialist to review an insured’s condition and care and to plan treatment paths for the insured that meet their medical needs in a manner that mitigates unnecessary cost.

What is the morbidity for diabetes in males aged 41 to 50 if there are 49 incidences per thousand?

The three primary actuarial factors are…

Which, if any, of the following statements are correct regarding “risk-profiles”?
Statement I. Preferred risks have a better-than-average “risk profiles”.
Statement II. Uninsurable risks have “risk profiles” that are so low they cannot be written actuarially in a profitable way.

______________________ integrate the financing and delivery of health care services to contain cost and to provide health care and services as efficiently as possible.

Individual premiums paid for Disability Income policies are not tax deductible and ___________ received are not taxed to the insured.

Yuhong Song’s HMO is using which “medical cost management” approach when asking her to get a “required” second opinion before having a procedure?

True or False? Health care claims increase across all ages; the older an insured the higher the insurance premium.

Which of the following are insurance company/insurance policy expenses?

All of the following are risk factors in Health Insurance underwriting EXCEPT?

The NAIC’s main objective is the formation of a code of _______ for the industry.

The Relation of Earnings to Insurance provision helps to keep an insured from unrealistically over-purchasing ___________ insurance?

Jerry has a policy which is “Conditionally Renewable”. The insurance company has the contractual option to cancel the policy but any cancellation is limited to…

The _________________ provision allows the insurer to adjust the premium if either the age or sex of the application was misstated on the application of insurance.

The Notice of Claim provision requires the insured to place the insurance company on notice of a claim “within a __________ period of time”.

Micah failed to make his scheduled monthly payment and he did not make the payment within the 30 day grace period. He has filed a reinstatement application with the company which was accepted. A week after the reinstatement Micah filed a claim for bronchitis which was denied…

Johanna is late with her Health Insurance monthly payment by fourteen days.

Does Johanna’s insurance company have to accept her late payment?

True or False? The Time Limit on Certain Defenses provision allows a bar of coverage after the incontestable period in the policy has expired.

How does the “entire contract” provision protect an insured?

Kara got hurt rollerblading January 1st; she would have until what date to submit a proof of loss to have her claim paid?

True or False? The Claim Forms provision places the burden on the insurance company to provide an insured with a claim form within sixty (60) days from the notice of claim.

Juliette has a son turning twenty-six next year and she is concerned that he will not be eligible for coverage on her Health Insurance plan. How will you help Julliette with her son’s Health Insurance coverage?

Jerry has a policy which is “Optionally Renewable”. The insurance company has the contractual option to cancel the policy but any cancellation is limited to….

Justyn owns a life insurance policy on himself and wants to change the beneficiary on the policy; he can change the policy beneficiary at any time unless the beneficiary is __________.

Kara got hurt rollerblading January 1st; and filed her Proof of Loss on April 1st. By what date must the insurance company pay Kara’s claim?

Kevin has had a change in his occupation; which policy type is most affected by this change in occupation?

The NAIC provision “Legal Actions” provision requires an insured to wait until 60 days after filing a proof of loss with the insurance company before any formal ______ action can be taken against the insurer.

You are selling Mrs. Jane Wilson a Long Term Care policy. She would like to keep the premium as low as possible.
What is the maximum elimination period that can be applied to a Florida policy?

Long-Term Care normally refers to care of ___ days or longer in an adult day care, nursing home, or at the insured’s home.

Ten Koney was hospitalized and used Medicare and his Medigap Plan A benefits to pay for all of his hospital expenses. He is now in need of long term custodial care.

LTC benefits are ___________ if they conform to HIPPA, the IRC, and follow model NAIC long-term care provisions.

True or False? Home Health Care is in the insured’s home and Adult Day Care is in a commercial facility.

*Skilled Nursing* care is continuous, around-the-clock care provided by licensed medical professionals under the direct supervision of a __________.

Activities of Daily Living (ADLs) are the self care activities of:

HIPAA compliant LTC policies are required to be _______________ (the policy cannot be cancelled as long as premiums are paid; up to a term of years or attained age).

Elizabeth is not longer able to bathe, dress, or get in and out of bed by herself.

Is Elizabeth eligible for LTC coverage?

Medigap policies pay health care cost that Medicare does not such as:

Cassidy Jones has purchased a Medigap policy which her agent delivered to her ten days ago. Mrs. Jones has decided she does not want the policy.

Long-Term Care services include services required by the chronically ill and/or cognitively impaired including all but which of the following?

Juliana Clifford has a 60 day elimination period and LTC daily benefits of $250 per day. If she has been in long term care for 100 days will she incur any taxation on any benefits received?

Ralph Keith’s LTC policy pays up to $125 per day in a nursing home and up to $75 per day for at-home care.
Keith has been at the Mountain State Elder Care facility for eight weeks and he has racked up a bill of $5,000.

How much will Ralph’s LTC policy pay towards his bill?

Which benefits are covered by Medicaid which are not covered by Medicare?

Medicaid Reform in 2005 provided flexibility in benefits with a focus on __________________ in hopes of reducing Medicaid cost.

The ___________________ program was created to provide health insurance to uninsured children.

Which, if any, of the following concerning Medicare Part C are correct.

Greg is Medicare eligible and is employed at Walmart and has health insurance through Walmart. Greg is hospitalized for 14 days and has $9,000 in doctor’s expenses.

Medicare Part A provides a lifetime reserve of 60 days of hospital coverage when a patient has exceeded ___days of coverage in a benefit period.

Medicare Part A covers Hospice care for the terminally ill patients. Hospice eligibility requires a doctor to certify the patient has a ______ month or less life expectancy.

True or False? Medicare will pay for a private hospital room but will not pay for private duty nursing.

Juanita’s hospitalization would be covered by Medicare Part A and her surgeon’s expenses would be covered under ______________.

True or False? The federal government created Medicare to provide medical care to the rich and the famous.

Juanita is eligible for Medicare and has been hospitalized for the last 59 days.

How will Medicare assist Juanita for her hospital expenses?

What is the Medicare “donut hole”?

Medicare Part B pays ___% of covered expenses after the deductible has been exhausted.

Medicare Advantage plans pay for ____________________ basis rather than on a pay-per-service basis.

Which, if any, of the following statements are correct?

Statement I. Medicare Part A covers hospital expenses.

Statement II. Medicare Part B covers health insurance coverage.

Medicare is funded by employee and employer FICA contributions. Employees contribute 1.45% of all earned wages for Medicare. What amount if any is contributed by the employer?

Workers Compensation insurance and/or benefits are required by state law and are an __________________ for employees when injured in work related activities.

Jan Bridges was injured in the course and scope of her employment and has incurred medical expenses, lost wages, and non-economic loss due to pain and suffering.

Can Workers Compensation help Jan with any of these expenses/losses? (select all that apply)

All of the following are eligible for Medicare coverage EXCEPT?

Travel Insurance is an example of which type of policy?

If an insured were to die in a hang gliding accident how would an AD&D policy with only the “accidental means” language in it respond to a claim?

The amount payable for death in an AD&D policy is known as the policy’s _____________.

The amount payable for dismemberment of loss of a stipulate body part or function in an AD&D policy is known as the policy’s ___________.

True or False? Accidental Death and Dismemberment policies pay a lump-sum benefit in the event of an accidental death or injury.

Examples of special risk policies might include insuring: (select all that apply)

Dr. Juliet Molar was involved in a serious automobile accident and is no longer capable of working in her dental practice. If she is capable of teaching would she meet the “any occupation” definition of being disabled?

Betty Turner was injured hanging curtains in her spare bedroom one sunny spring day. Unfortunately Betty had difficulty raising her right arm and turning her head or torso to the right and she was out of work for six months. When she came back to work she re-injured her neck in the first month and is again incapable of performing her regular duties at the Fred Astaire Dance Studio.

What provision in a DI policy is controlling when determining if a new elimination period starts with the re-injury or if the re-injury is considered part of the original disability?

Claudio earns $3,000 a month and has a Disability Income policy which pays $2,100 of his earnings as a flat income benefit. If Claudio becomes totally disabled what amount will his DI monthly benefit be?

Which, if any, of the following statements are correct?

Statement I. Group DI policies normally pay on a percentage of income basis.
Statement II. Individual DI policies normally pay on a percentage of income basis.
Statement III. Group DI policies normally pay on a flat/stated amount basis.
Statement IV. Individual DI policies normally pay on a flat/stated amount basis.

True or False? Accidental Means is the most stringent disability provision.

Calculate Sam’s partial disability benefit if he can only work half-time now and she was previously receiving $900 a week and is being paid a “flat amount” of 60% for the last twelve weeks.

Shelly has suffered a serious injury and cannot sit or stand for long periods of time. Shelly has returned to work but she cannot sit or stand for long periods of time in her capacity as a butcher. Shelly’s doctor has limited her to no more than four hours per day.

Which, if any, of the following are considered a presumptive total disability?

Chris Johnson has a Disability Income policy with a sixty day probationary period. Three weeks after the policy went into force Chris breaks his leg playing church softball.

Will Chris be able to make a compensable DI claim?

Which of the following occupations are most likely to have a “non-occupational” type Disability Income policy?

Becky has purchased a DI rider which increases benefits over time to keep up with inflation.

What must happen before an insured can successfully file a Disability Income claim under the DI Social Security rider?

You have explained to your insured that Disability Income Insurance is very important as part of an overall plan to protect the insured against the financial loss of wages due to an injury, illness, accident or sickness.

What might you say to your proposed insured to encourage her to protect against this exposure to loss of income?

High Deductible Health Care Plans are characterized by:

The insured has a Basic Medical Expense plan that pays up to $10,000 for any occurrence. The insured also carries a Supplemental Major Medical policy with a $1,000 “integrated deductible”. The insured suffers a $16,000 loss.

How much if any will the Supplemental Major Medical plan cover?

The insured has a Basic Medical Expense plan that pays up to $10,000 for any occurrence. The insured also carries a Supplemental Major Medical policy with a $500 deductible. The insured suffers a $12,500 loss.

How much if any will the Supplemental Major Medical plan cover?

The insured has $10,000 of medical expenses and his Major Medical Expense policy has a $1,000 deductible and a 80% coinsurance provision.

How much will the insured absorb of the loss taking his deductible and coinsurance percentage into consideration?

How much will the insurance company pay if an insured has $250,000 of medical expenses and his Major Medical policy has a $10,000 deductible and a 90% coinsurance provision with a “Maximum Out-of-Pocket” provision stating the insured will not pay over $10,000 during the policy term?

Sheronda has a Basic Medical Expense plan and a Supplementary Major Medical Expense plan. If Sheronda has a $15,000 hysterectomy and her Basic Medical Expense plan covers $10,000 of the cost how much will her Supplementary Major Medical plan pay?

After a careful review Autumn revealed that she had purchased a Basic Medical Expense plans covering only specific, select, and narrowly defined medical care issues. What she really wanted was a ________________ plan to cover on a more comprehensive basis with coverage on a broader basis.

What are the lifetime policy limits for ACA compliant Major Medical Expense Insurance Plans?

Which of the following are covered in a Major Medical insurance policy?

Basic Surgical Expense insurance provides benefits on a (pick as many as apply):

Peggy has a Basic Hospital Expense policy which pays $150 a day up to 30 days. Peggy was in the hospital for 45 days and the cost per day was $125.

How much with the insurance company pay Peggy?

Kara has a “fixed-rate policy” which pays on a scheduled basis. Dolores’ policy pays for actual cost incurred.

What type of payment approach is in Dolores’ policy?

To meet the OASDI “Disabled” definition an individual must be mentally or physically disabled to the extent that she cannot perform any substantial gainful work and the determination requires the disability to have an expected duration of __ months or longer.

The _____________________ requires employers with twenty-five (25) or more employees to offer enrollment in an HMO if health care benefits are offered to employees.

All of the following are parties to the “service provider” approach to healthcare/health insurance EXCEPT?

Disabled employees are entitled to workers compensation benefits as ________________ without having to sue their employer for benefits BUT the employee correspondingly gives up the right to sue the employer.

Erik has met the OASDI definition of “disabled for the past eleven months.

Does he qualify for OASDI Disability benefits?

Medicare provides programs of health insurance for:

Point-of-Service Plans authorize and _________ subscriber referrals to specialist and hospitals.

Which of the following, if any, are characteristics of Preferred Provider Organizations?

The right of assignment built into most commercial health policies lets policyowners _______ benefit payments from the insurer directly to the health care provider

Employer “Self-Insured Plans” are administered by which of the following?

Bill Hoover’s Health Insurance policy has a renewability provision which allows the insurer to non-renew the policy at the policy’s anniversary date.

What renewability provision is in Bill Hoover’s Health Insurance policy?

Jeremy has a Health Insurance policy with a renewal provision that does not allow the insurance company to cancel the policy and his rates cannot be increased subject to an age attainment provision in the policy.

Which renewability provision is in Jeremy’s Health Insurance policy?

Lucky Charms has a(n) _________ rating plan which provides either a retroactive discount or future credit on their next renewal based upon the insured’s favorable loss history and expenses.

Individuals and families that make ______ of the Federal Poverty Level (FPL) are ACA subsidy eligible.

Kathy wants to purchase an insurance policy that will provide income to her if she becomes disabled and unable to work.

What type of insurance would you recommend for Kathy?

Darnell’s Health Insurance policy has a renewable provision which allows the insurer to non-renew his policy but only for specified reasons stated in the policy.

Which renewability provision is in Darnell’s Health Insurance policy?

Which, if either, of the following are correct?

Statement I. Loss Reserves are set aside for future claims.

Statement II. Premium Reserves are set aside for current claims.

The Affordable Care Act requires employers with 50 or more employees to provide health insurance or pay a fine of $______ per worker for any worker receiving federal subsidies to purchase health insurance.

If you have an ACA compliant Health Insurance policy up to what age will your insurance policy and insurance company allow you to keep your graduate student daughter on your policy?

_____________ is the unethical act of persuading a client to cancel a policy for the purpose of selling them another policy without regard to any negative affect it may have on the client.

True or False? Life insurance should not be described or implied as a savings or retirement plan.

Which, if any, of the following statements are correct?

Statement I. An “unauthorized” insurer is one duly authorized by a subsisting certificate of authority issued by the department to transact insurance in this state.

Statement II. An “authorized” insurer is one not so authorized.

Unfair discrimination takes place in the sales or underwriting process when adverse decisions are made based on characteristics such as:

____________ selling is presenting products that meet specific needs of clients so the client can make their own decisions about what products are best for them.

True or False? The NAIC model regulations state that illustrations must not contain words like invisible premium.