IC-38 Insurance Agent Exam - Health cheat sheet
IC-38 Insurance Agent Exam - Health · Keep the key ideas within reach.
Health Insurance
Health insurance is a contract in which the insurer pays specified medical or disability benefits in exchange for premium; the policy, endorsements, and application form the entire contract.
Indemnity (fee-for-service) plans reimburse actual charges subject to deductible, coinsurance, and internal limits; managed care plans (HMO, PPO, POS) instead contract with networks and use utilization controls.
HMO: members generally must use in-network providers and a primary care physician (PCP) for referrals; care outside the network is typically not covered except emergencies. PPO: in-network care costs less, out-of-network care is covered at a reduced benefit with no referral requirement.
POS combines HMO and PPO features: a PCP coordinates care, in-network services use a copay, out-of-network services are allowed with a referral and higher cost sharing.
Cost-sharing terms: deductible is the amount the insured pays before benefits begin; coinsurance is the insured's fixed percentage of covered charges after the deductible; a copayment is a flat dollar amount per service; an out-of-pocket maximum caps annual insured cost sharing.
Major medical policies contain internal limits (caps on specific services), exclusions, a preexisting-condition provision where permitted, and coordination-of-benefits rules that determine primary versus secondary payer when two plans cover the same loss.
Disability income insurance replaces a percentage of income (commonly 50-70%) after an elimination period; benefits depend on the definition of disability (own occupation versus any occupation), benefit period, and residual or partial disability provisions.
Health insurance underwriting evaluates age, sex, occupation, health history, and lifestyle; classification determines rate class, and riders or exclusions may be attached for substandard risks.
Claims: a notice of claim and proof of loss are required within the time limits stated in the policy; the insurer must provide claim forms, and the insured must submit authorization for release of medical information.