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Virginia Health Insurance Examination — Information & Free Practice

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Virginia Health Insurance Examination

Provider
Prometric
Format
Computer-administered four-option multiple-choice examination
Exam questions
90 scored questions and 15 pretest questions
Time limit
2 hours
Exam fee
$35
Examination outline
  • 1.0 Insurance Regulation (17%)
    • 1.1 Licensing General Provisions and Definitions (38.2-1800) Process (38.2-1819) Types of licensees Agents (38.2-1800.1(A), 1801, 1814–1815.1, 1817–1818, 1822(A), (B), 1824) Consultants (38.2-1837–1840) Nonresidents (38.2-1836, 1845) Business entities (38.2-1800.1(B), 1820, 1822(C), (D)) Exceptions (38.2-1821.1, 1822 (G )) Maintenance Duration and termination (38.2-1825, 1826) Address and/or name changes (38.2-1826(A)) Assumed names (38.2-1822(E), (F)) Requirement to report felony convictions (38.2-1826(B)) Requirement to report other states actions (38.2-1826(C)) Continuing education (38.2-1866, 1868.1–1871) Appointment procedures (38.2-1825, 1833–1834.1) Agent's contract with insurer versus agent's appointment with insurer Agent's appointment versus agency's appointment Solicitation prior to appointment Appointment requirement after becoming licensed Acknowledgment of appointment/notice to agent Requirement to cease solicitation Termination of appointment/notice to agent Termination of license without active appointment Disciplinary actions Probation, suspension, revocation or refusal to issue or renew (38.2-1821, 1831, 1832) Cease and desist order (38.2-219) Penalties (38.2-218, 1823)
    • 1.2 State regulation State Corporation Commission's general duties and powers (38.2-200) Agent regulation Acting for an unlicensed insurer (38.2-1802) Record retention (38.2-1809(B)) Activities of unlicensed individuals (38.2-1821.1(B), 1822(G); AL 2002-9) Payment and sharing of commissions (38.2-1812) Charging of fees (38.2-310) Illegal compensation; exceptions (38.2-1812.2) Fiduciary capacity (38.2-1813) Responsibility of trust accounts (38.2-1813) Unfair trade practices Misrepresentation (38.2-502, 512) False advertising (38.2-503) Defamation (38.2-504) Boycott, coercion and intimidation (38.2-505) Notice of Adverse Underwriting Decisions (38.2-610) False statements and entries (38.2-506) Unfair Discrimination (38.2-508, 38.2-508.1, 38.2-508.2) Rebating (38.2-509) Twisting (38.2-1831(5)) Referrals (38.2-1821.1 (B) 8) Insurance information and privacy protection (38.2-604, 613) Notice of information practices (38.2-604, 613, 608, 609, 38.2-604.1)
    • 1.3 Federal regulation Fair Credit Reporting Act (15 USC 1681–1681d) Fraud and false statements (18 USC 1033, 1034) Continuation (38.2-3541) ACA-Related Federal Market Reforms (Article 6, 38.2-3438 through 3454.1) Definitions (38.2-3438) Individual health insurance coverage Dependent coverage (38.2-3439) Lifetime and annual limits (38.2-3440) Restrictions relating to premium rates (38.2-3447) Essential health benefits (38.2- 3451) Waiting periods (38.2-3452) Excepted benefits (45 CFR § 148.220), (38.2-3431)
    • 1.4 Industry regulation National Association of Insurance Commissioners (NAIC)
  • 2.0 General Insurance (10%)
    • 2.1 Concepts Risk management key terms Risk Exposure Hazard Peril Loss Methods of handling risk Avoidance Retention Sharing Reduction Transfer Elements of insurable risks Adverse selection Law of large numbers Reinsurance
    • 2.2 Insurers Types of insurers Stock companies Mutual companies Fraternal benefit societies Self insurers Private versus government insurers Admitted versus nonadmitted insurers Domestic, foreign and alien insurers Financial status (independent rating services) and operating results Marketing (distribution) systems
    • 2.3 Agents and general rules of agency Types Captive Independent Insurer as principal Agent of insurer Authority and powers of agents Express Implied Apparent Responsibilities to the applicant/insured
    • 2.4 Contracts Elements of a legal contract Offer and acceptance Consideration Competent parties Legal purpose Distinct characteristics of an insurance contract Contract of adhesion Aleatory contract Personal contract Unilateral contract Conditional contract Legal interpretations affecting contracts Ambiguities in a contract of adhesion Reasonable expectations Indemnity Utmost good faith Representations/misrepresentations Warranties Concealment Fraud Waiver and estoppel
  • 3.0 Health Insurance Basics (12%)
    • 3.1 Definitions of perils Accidental injury Sickness
    • 3.2 Principal types of losses and benefits Loss of income from disability Medical expense Dental expense Long-term care expense
    • 3.3 Classes of health insurance policies Individual versus group Private versus government Limited versus comprehensive
    • 3.4 Limited policies Limited perils and amounts Required notice to insured Types of limited policies Accident-only Specified (dread) disease Hospital indemnity (income) Credit disability Blanket insurance (teams, passengers, other) Prescription drugs Vision care Critical illness (specified conditions) Short-term medical
    • 3.5 Common exclusions from coverage Pre-existing conditions Intentionally self-inflicted injuries War or act of war Elective cosmetic surgery Conditions covered by workers compensation Government plans Participation in a felony or illegal occupation (38.2-3504 10)
    • 3.6 Agent responsibilities in individual health insurance Marketing requirements Advertising (14 VAC 5-90) Life, Accident and Sickness Insurance Guaranty Association (38.2-1715) Sales presentations Field underwriting Nature and purpose Application procedures Requirements at delivery of policy Notification of Medicare eligibility
    • 3.7 Individual underwriting by the insurer Sources of underwriting information Application Agent report Attending physician statement Investigative consumer (inspection) report Medical Information Bureau (MIB) Medical examinations and lab tests (including HIV consent) (38.2-613.01; 14 VAC 5-180-50) Unfair discrimination (38.2-508, 38.2-508.1, 38.2-508.2) Genetic information privacy (38.2-508.4, 38.2-613 D) Classification of risks Preferred Standard Substandard Declined
    • 3.8 Considerations in replacing health insurance Pre-existing conditions (38.2-3514) Pre-existing condition exclusion (38.2-3514.1) Benefits, limitations and exclusions Underwriting requirements Virginia replacement requirements (14 VAC 5-141-150)
  • 4.0 Individual Health Insurance Policy General Provisions (16%)
    • 4.1 Uniform required provisions (38.2-3503 A) Entire contract; changes Time limit on certain defenses Grace period Reinstatement Notice of claim Claim forms Proofs of loss Time of payment of claims Payment of claims Physical examinations and autopsy Legal actions Change of beneficiary Cancellation by insured
    • 4.2 Uniform optional provisions (38.2-3504) Change of occupation Misstatement of age Other insurance in this company Insurance with other companies Expense-incurred basis Other than expense-incurred Unpaid premium Cancellation by company Conformity with state statutes Illegal occupation Intoxicants and narcotics
    • 4.3 Other general provisions Right to examine (free look) (38.2-3502) Insuring clause Consideration clause Renewability clause (38.2-3514.2; 14 VAC 5-141-30 C and 14 VAC 5-141-140 A and C) Noncancelable Guaranteed renewable Conditionally renewable Renewable at option of insurer Nonrenewable (cancelable, term) Interest on claim proceeds (38.2-3407.1) Military suspension provision (14 VAC 5-141-30 I)
  • 5.0 Disability Income and Related Insurance (9%)
    • 5.1 Qualifying for disability benefits Inability to perform duties Own occupation Any occupation Pure loss of income (income replacement contracts) Presumptive disability Requirement to be under physician care
    • 5.2 Individual disability income insurance (14 VAC 5-141-60) Basic total disability plan Income benefits (monthly indemnity) Elimination and benefit periods Waiver of premium benefit Additional monthly benefit (AMB) Social insurance supplement (SIS) Occupational versus nonoccupational coverage At-work benefits Partial disability benefit Residual disability benefit Other provisions affecting income benefits Cost of living adjustment (COLA) rider Future increase option (FIO) rider Annual renewable term rider Relation of earnings to insurance (38.2-3504(6)) Change of occupation Other cash benefits Accidental death and dismemberment Rehabilitation benefit Medical reimbursement benefit (nondisabling injury) Refund provisions Return of premium Cash value benefit Exclusions
    • 5.3 Unique aspects of individual disability underwriting Occupational considerations Benefit limits Policy issuance alternatives
    • 5.4 Group disability income insurance (14 VAC 5-141-60) Group versus individual plans Short-term disability (STD) Long-term disability (LTD)
    • 5.5 Business disability insurance Key employee (partner) disability income Business overhead expense policy Business Disability buyout policy
    • 5.6 Social Security disability Qualification for disability benefits Definition of disability Waiting period Disability income benefits
    • 5.7 Workers compensation Eligibility Benefits
  • 6.0 Medical Plans (10%)
    • 6.1 Medical plan concepts Fee-for-service basis versus prepaid basis Specified coverages versus comprehensive care Benefit schedule versus usual/reasonable/customary charges Any provider versus limited choice of providers Insureds versus subscribers/participants
    • 6.2 Types of providers and plans Major medical insurance (insurers) Characteristics Common limitations Common exclusions from coverage Deductibles Coinsurance feature Stop-loss feature Maximum benefits Health services plans Definitions (38.2-4201) Plans offered (38.2-4202–4204, 4209) Other services (38.2-4205) Qualified providers (38.2-4221) Choice of provider or pharmacy (38.2-4209.1, 4218) Provider panels (38.2-3407.10) Disclosure of benefits (38.2-4219) Subscribers Health maintenance organizations (HMOs) (38.2-4300–4323; 14 VAC 5-211-10-280) Combined health care delivery and financing Limited service area/out of area benefits Limited choice of providers Gatekeeper concept Copayments Prepaid basis Preventive care services Primary care physician versus referral (specialty) physician Emergency care Hospital services Other basic services Subscribers Preferred provider organizations (PPOs) General characteristics Open panel or closed panel Point-of-service (POS) plans Nature and purpose Out-of-network provider access (open-ended HMO) PCP referral Indemnity plan features TRI-CARE Virginia Family Access to Medical Insurance Security Plan (FAMIS) (RL 32.1-351)
    • 6.3 Cost containment in health care delivery Cost-saving services Preventive care Outpatient ambulatory services Alternatives to hospital services Utilization management Prospective review Concurrent review
    • 6.4 Virginia eligibility requirements Dependent child age limit (38.2-3500(C), 3525) Coverage for adopted children (38.2-3411.2) Newborn child coverage (38.2-3411) Medical child support coverage (38.2-3407.2) Intellectual disability and physical handicap dependent coverage (38.2-3409)
    • 6.5 HIPAA (Health Insurance Portability and Accountability Act) requirements (38.2-3430.1–.9, 3432.1–.3) Eligibility Guaranteed issue Pre-existing conditions Creditable coverage Renewability
    • 6.6 Health Savings Accounts (HSAs) and Health Reimbursement Accounts (HRAs) Definition Eligibility Contribution limits
  • 7.0 Group Health Insurance (8%)
    • 7.1 Characteristics of group insurance Group contract Certificate of coverage (38.2-3533) Experience rating versus community rating
    • 7.2 Defined groups (38.2-3521.1) Employer Creditor Labor union Association Credit union
    • 7.3 Marketing considerations Advertising Regulatory jurisdiction/place of delivery
    • 7.4 Employer group health insurance Insurer underwriting criteria Characteristics of the group Plan design factors Persistency factors Administrative capability Eligibility for insurance Annual open enrollment Employee eligibility Dependent eligibility Coordination of benefits provision Change of insurance companies or loss of coverage Coinsurance and deductible carryover No-loss no-gain Events that terminate coverage Reinstatement of coverage for military personnel (38.2-508.1(B)) Notification of Medicare eligibility Extension of benefits Continuation of coverage under COBRA and Virginia specific rules (38.2-3541)
    • 7.5 Small employer medical plans (38.2-3431–3437) Definition of small employer (38.2-3431) Availability of coverage (38.2-3431(C), 3432.2) Disclosure of coverage provisions (38.2-3434) Enrollment eligibility (38.2-3436) Renewability (38.2-3432.1)
  • 8.0 Dental Insurance (14 VAC 5-141-70) (2%)
    • 8.1 Types of dental treatment Diagnostic and preventive Restorative Oral surgery Endodontics Periodontics Prosthodontics Orthodontics
    • 8.2 Indemnity plans Choice of providers Scheduled versus nonscheduled plans Benefit categories Diagnostic/preventive services Basic services Major services Deductibles and coinsurance Combination plans Exclusions Limitations Predetermination of benefits
    • 8.3 Employer group dental expense Integrated deductibles versus stand-alone plans Minimizing adverse selection
  • 9.0 Insurance for Senior Citizens and Special Needs Individuals (14%)
    • 9.1 Medicare Nature, financing and administration Part A — Hospital Insurance Individual eligibility requirements Enrollment Coverages and cost-sharing amounts Part B — Medical Insurance Individual eligibility requirements Enrollment Coverages and cost-sharing amounts Exclusions Claims terminology and other key terms Part C — Medicare Advantage Part D — Prescription Drug Insurance
    • 9.2 Medicare supplement insurance (14 VAC 5-170-10–220, 38.2-3600 – 38.2-3611) Purpose (14 VAC 5-170-10) Open enrollment (14 VAC 5-170-100) Rating of Medicare supplement plans (14 VAC 5-170-30) Attained age Issue age Community rated Standardized Medicare supplement plans (14 VAC 5-170-75, 85, 87) Core benefits Additional benefits High deductible plans Virginia regulations and required provisions Standards for marketing (14 VAC 5-170-180) Advertising (38.2-3609; 14 VAC 5-170-170) Appropriateness of recommended purchase and excessive insurance (14 VAC 5-170-190) Buyer's guide (14 VAC 5-170-150(A)(6)) Outline of coverage (38.2-3606; 14 VAC 5-170-150(D)) Right to return (free look) (38.2-3604; 14 VAC 5-170-150(A)(5)) Replacement (14 VAC 5-170-160, 210) Prohibited policy provisions (14 VAC 5-170-210) Minimum benefit standards (14 VAC 5-170-75) Required disclosure provisions (14 VAC 5-170-150) Pre-existing conditions (38.2-3605) Permitted compensation (14 VAC 5-170-140) Guaranteed issue for eligible persons (14 VAC 5-170-105) Continuation and conversion requirements (14 VAC 5-170; 14 VAC 5-170-75 B 7 (a)(b)(c)(d)) Medicare SELECT (14 VAC 5-170-90) Medicare supplement policies for person eligible by reason of disability (38.2-3610) (14 VAC 5-170-87 (A) (2))
    • 9.3 Other options for individuals with Medicare Employer group health plans Disabled employees Employees with kidney failure Individuals age 65 and older Medicaid Eligibility Benefits
    • 9.4 Long-term care (LTC) policies (38.2-5200–5210; 14 VAC 5-200-10–210) LTC, Medicare and Medicaid compared Eligibility for benefits (14 VAC 5-200-187) Levels of care Skilled care Intermediate care Custodial care Home health care (14 VAC 5-200-50, 90) Adult day care (14 VAC 5-200-50) Respite care Benefit periods Benefit amounts Optional benefits Guarantee of insurability Return of premium Qualified LTC plans (14 VAC 5-200-40) Deductibility of premiums for LTC insurance for state income tax purposes Exclusions (14 VAC 5-200-60(B)) Underwriting considerations Virginia regulations and required provisions Standards for marketing (14 VAC 5-200-170) Advertising (14 VAC 5-200-160) Consumer guide (38.2-5207(3)) Outline of coverage (38.2-5207, 5207.1; 14 VAC 5-200-200) Suitability including personal worksheet (14 VAC 5-200-175) Right to return (free look) (38.2-5208) Replacement (14 VAC 5-200-110, 190) Renewal considerations (14 VAC 5-200-60(A)) Continuation of benefits (14 VAC 5-200-60(D)) Required disclosure provisions (14 VAC 5-200-70) Incontestability (38.2-5209) Inflation protection (14 VAC 5-200-100) Unintentional lapse (14 VAC 5-200-65) Pre-existing conditions (38.2-5204; 14 VAC 5-200-190) Nonforfeiture benefit (38.2-5210; 14 VAC 5-200-185) Benefit triggers (14 VAC 5-200-70(G), 187)
  • 10.0 Federal Tax Considerations for Health Insurance (2%)
    • 10.1 Personally-owned health insurance Disability income insurance Medical expense insurance Long-term care insurance
    • 10.2 Employer group health insurance Disability income (STD, LTD) Medical and dental expense Long-term care insurance Accidental death and dismemberment
    • 10.3 Medical expense coverage for sole proprietors and partners
    • 10.4 Business disability insurance Key person disability income Business overhead expense Business Disability Buyout
    • 10.5 Health Savings Accounts (HSAs), Health Reimbursement Accounts (HRAs), and Flexible Spending Accounts (FSAs) Health Savings Accounts Health Reimbursement Accounts Flexible Spending Accounts High Deductible Health Plans
Examination sources