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Virginia Health Insurance — Requirements & Free Practice

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Health agent

Health qualification for individual and business entity insurance producers; resident and reciprocal nonresident routes.

Licensing authority: Virginia State Corporation Commission, Bureau of Insurance · Application information

Resident individual — moving with an active Virginia nonresident licence
No examination is required for this applicant pathway.
Appointments
Existing appointments convert automatically when equivalent resident authority is obtained during the 90-day period; otherwise the nonresident licence and appointments terminate.
Board Moving Instruction
SCC requires inactivation of the former resident licence and exempts the corresponding exams and fingerprinting for applications within 90 days of inactivation.
Prior Status
Hold an active Virginia nonresident health licence; apply for equivalent resident authority and pay the fee within the statutory 90-day transition.

Official no-examination sources

Effective from 2026-09-22.

Resident individual — moving without a Virginia nonresident licence
No examination is required for this applicant pathway.
Authority
Only previously held lines are exempt from the prelicensing examination, except where the Commission determines otherwise by regulation.
Board Moving Instruction
SCC requires the previous resident licence to be inactivated and instructs applicants to apply within 90 days of inactivation to receive the exam and fingerprint exemption.
Deadline
Apply and pay within 90 days after establishing Virginia residence; otherwise satisfy all resident prelicensing requirements.
Operations
No sale, solicitation or negotiation in Virginia before obtaining resident authority.
Prior Status
Previously licensed producer in another state or Canadian province; no existing Virginia nonresident licence.

Official no-examination sources

Effective from 2026-09-22.

Nonresident business entity — reciprocal health qualification
No examination is required for this applicant pathway.
Applicant Type
Business entity, excluding sole proprietorships.
Application
Submit the proper request, processing fee, and home-state application or completed Uniform Application; home-state status may be verified through the NAIC Producer Database.
Assumed Name
Notify the Bureau of an assumed or fictitious name at application or within 30 days of adoption (§ 38.2-1822 E).
Business Registration
The entity must be recorded pursuant to law; SCC instructions require Clerk registration within 90 days of obtaining the agency licence.
Continued Authority
Equivalent home-state authority must remain active (§ 38.2-1836 G).
Designated Producer
Designate an appropriately licensed employee, officer, director, manager, member or partner responsible for compliance; the individual producer licence is a qualification of the entity, not an examination required of the entity.
Home State Licence
Currently resident-licensed and in good standing for equivalent authority in the home state; the home state must grant reciprocal nonresident licences to Virginia residents.

Official no-examination sources

Effective from 2026-09-22.

Nonresident business entity — new licence after termination or revocation
No examination is required for this applicant pathway.
Applicant Type
Business entity, excluding sole proprietorships.
Application
Submit the proper request, processing fee, and home-state application or completed Uniform Application; home-state status may be verified through the NAIC Producer Database.
Assumed Name
Notify the Bureau of an assumed or fictitious name at application or within 30 days of adoption (§ 38.2-1822 E).
Business Registration
The entity must be recorded pursuant to law; SCC instructions require Clerk registration within 90 days of obtaining the agency licence.
Continued Authority
Equivalent home-state authority must remain active (§ 38.2-1836 G).
Designated Producer
Designate an appropriately licensed employee, officer, director, manager, member or partner responsible for compliance; the individual producer licence is a qualification of the entity, not an examination required of the entity.
Disciplinary Waiting Period
Where applicable, five years following the Commission order or the other period prescribed; entity must exist and satisfy licensing requirements again.
Home State Licence
Currently resident-licensed and in good standing for equivalent authority in the home state; the home state must grant reciprocal nonresident licences to Virginia residents.

Official no-examination sources

Effective from 2026-09-22.

Nonresident business entity — biennial renewal
No examination is required for this applicant pathway.
Renewal Cycle
Beginning May 1, 2021 and biennially thereafter, submit the entity renewal application and processing fee; meet other applicable licensing provisions.
Responsible Producer
Maintain a designated licensed producer.

Official no-examination sources

Effective from 2026-09-22.

Nonresident individual — reciprocal licensure
No examination is required for this applicant pathway.
Application
Submit the proper request, processing fee, and home-state application or completed Uniform Application; home-state status may be verified through the NAIC Producer Database.
Continued Authority
Equivalent home-state authority must remain active (§ 38.2-1836 G).
Home State Licence
Currently resident-licensed and in good standing for equivalent authority in the home state; the home state must grant reciprocal nonresident licences to Virginia residents.

Official no-examination sources

Effective from 2026-09-22.

Nonresident individual — new reciprocal licence after termination, refusal or revocation
No examination is required for this applicant pathway.
Application
Submit the proper request, processing fee, and home-state application or completed Uniform Application; home-state status may be verified through the NAIC Producer Database.
Continued Authority
Equivalent home-state authority must remain active (§ 38.2-1836 G).
Disciplinary Waiting Period
Where applicable, five years after the refusal or revocation order, or the other period the Commission prescribes.
Home State Licence
Currently resident-licensed and in good standing for equivalent authority in the home state; the home state must grant reciprocal nonresident licences to Virginia residents.

Official no-examination sources

Effective from 2026-09-22.

Nonresident individual — reinstatement within 12 months
No examination is required for this applicant pathway.
Application
Submit a renewal application, double the normal renewal processing fee, and satisfy relevant CE requirements.
Bulletin Demand
The Licensing Information Bulletin p.5 states: "If the license terminates for any reason, a resident must pass the examination again prior to applying for the license." Section 38.2-1825.1 E expressly allows this reinstatement without a prelicensing written examination and controls this route.
Time Limit
Licence terminated for failure to renew; reinstate within 12 months of the renewal date.
Waiver
Military service, long-term illness or incapacity may support a Commission waiver; statutory documentation and deadlines apply.

Official no-examination sources

Effective from 2026-09-22.

Nonresident individual — biennial renewal
No examination is required for this applicant pathway.
Continuing Education
Health or life-and-health category requires 16 relevant CE hours per biennium, including three ethics hours; multiple licence categories require 24 hours with at least eight per category. Statutory exemptions and approved waivers apply.
Home State CE
Nonresident CE exemption applies where home-state requirements are met and reciprocal credit is given.
Renewal Cycle
Individual renewal is biennial, at the end of the birth month in the matching odd/even birth year; submit renewal application and processing fee.

Official no-examination sources

Effective from 2026-09-22.

Resident business entity — health qualification
No examination is required for this applicant pathway.
Applicant Type
Business entity, excluding sole proprietorships.
Application
Submit the Uniform Business Entity Application and prescribed processing fee.
Assumed Name
Notify the Bureau of an assumed or fictitious name at application or within 30 days of adoption (§ 38.2-1822 E).
Business Registration
The entity must be recorded pursuant to law; SCC instructions require Clerk registration within 90 days of obtaining the agency licence.
Designated Producer
Designate an appropriately licensed employee, officer, director, manager, member or partner responsible for compliance; the individual producer licence is a qualification of the entity, not an examination required of the entity.

Official no-examination sources

Effective from 2026-09-22.

Resident business entity — new licence after termination or revocation
No examination is required for this applicant pathway.
Applicant Type
Business entity, excluding sole proprietorships.
Application
Submit the Uniform Business Entity Application and prescribed processing fee.
Assumed Name
Notify the Bureau of an assumed or fictitious name at application or within 30 days of adoption (§ 38.2-1822 E).
Business Registration
The entity must be recorded pursuant to law; SCC instructions require Clerk registration within 90 days of obtaining the agency licence.
Designated Producer
Designate an appropriately licensed employee, officer, director, manager, member or partner responsible for compliance; the individual producer licence is a qualification of the entity, not an examination required of the entity.
Disciplinary Waiting Period
Where applicable, five years following the Commission order or the other period prescribed; entity must exist and satisfy licensing requirements again.

Official no-examination sources

Effective from 2026-09-22.

Resident business entity — biennial renewal
No examination is required for this applicant pathway.
Renewal Cycle
Beginning May 1, 2021 and biennially thereafter, submit the entity renewal application and processing fee; meet other applicable licensing provisions.
Responsible Producer
Maintain a designated licensed producer.

Official no-examination sources

Effective from 2026-09-22.

Resident individual — initial licensure by examination

At least one of the following alternatives:

Applicant Type
Resident individual without a statutory prelicensing exemption.
Application
Submit the prescribed application and pay the nonrefundable processing fee; attach required background documents.
Character
Good character and a good reputation for honesty; Commission review of background disclosures.
Examination Choice
Pass Series 11-06 Health, or Series 11-01 Life, Annuities, and Health for both qualifications; these are independently registered official assessments.
Failed Examinations
After three failed attempts, wait 30 calendar days before retaking (§ 38.2-1817 B).
Minimum Age
At least 18 years of age (§ 38.2-1820 A).
Passing Score Window
Obtain the licence within 183 calendar days after passing; otherwise repeat the examination and applicable prelicensing requirements.
Resident Fingerprinting
Resident individuals applying for a new licence must provide fingerprints and pay for criminal history checks (§ 38.2-1819 B); current SCC instructions require usable fingerprints no older than 90 days, with the stated currently licensed same-type 12-month exception.
Resident individual — new licence after reinstatement period or other termination

At least one of the following alternatives:

Applicant Type
Resident individual without a statutory prelicensing exemption.
Application
Submit the prescribed application and pay the nonrefundable processing fee; attach required background documents.
Character
Good character and a good reputation for honesty; Commission review of background disclosures.
Examination Choice
Pass Series 11-06 Health, or Series 11-01 Life, Annuities, and Health for both qualifications; these are independently registered official assessments.
Failed Examinations
After three failed attempts, wait 30 calendar days before retaking (§ 38.2-1817 B).
Minimum Age
At least 18 years of age (§ 38.2-1820 A).
Passing Score Window
Obtain the licence within 183 calendar days after passing; otherwise repeat the examination and applicable prelicensing requirements.
Prior Termination
Prior licence terminated; 12-month reinstatement for failure to renew is unavailable or not invoked.
Resident Fingerprinting
Resident individuals applying for a new licence must provide fingerprints and pay for criminal history checks (§ 38.2-1819 B); current SCC instructions require usable fingerprints no older than 90 days, with the stated currently licensed same-type 12-month exception.
Resident individual — new licence following refusal or revocation

At least one of the following alternatives:

Applicant Type
Resident individual without a statutory prelicensing exemption.
Application
Submit the prescribed application and pay the nonrefundable processing fee; attach required background documents.
Character
Good character and a good reputation for honesty; Commission review of background disclosures.
Disciplinary Waiting Period
After refusal following a hearing or revocation, wait five years from the Commission order or the other period the Commission prescribes; comply again with all licensing requirements.
Examination Choice
Pass Series 11-06 Health, or Series 11-01 Life, Annuities, and Health for both qualifications; these are independently registered official assessments.
Failed Examinations
After three failed attempts, wait 30 calendar days before retaking (§ 38.2-1817 B).
Minimum Age
At least 18 years of age (§ 38.2-1820 A).
Passing Score Window
Obtain the licence within 183 calendar days after passing; otherwise repeat the examination and applicable prelicensing requirements.
Resident Fingerprinting
Resident individuals applying for a new licence must provide fingerprints and pay for criminal history checks (§ 38.2-1819 B); current SCC instructions require usable fingerprints no older than 90 days, with the stated currently licensed same-type 12-month exception.
Resident individual — reinstatement within 12 months
No examination is required for this applicant pathway.
Application
Submit a renewal application, double the normal renewal processing fee, and satisfy relevant CE requirements.
Bulletin Demand
The Licensing Information Bulletin p.5 states: "If the license terminates for any reason, a resident must pass the examination again prior to applying for the license." Section 38.2-1825.1 E expressly allows this reinstatement without a prelicensing written examination and controls this route.
Time Limit
Licence terminated for failure to renew; reinstate within 12 months of the renewal date.
Waiver
Military service, long-term illness or incapacity may support a Commission waiver; statutory documentation and deadlines apply.

Official no-examination sources

Effective from 2026-09-22.

Resident individual — biennial renewal
No examination is required for this applicant pathway.
Continuing Education
Health or life-and-health category requires 16 relevant CE hours per biennium, including three ethics hours; multiple licence categories require 24 hours with at least eight per category. Statutory exemptions and approved waivers apply.
Renewal Cycle
Individual renewal is biennial, at the end of the birth month in the matching odd/even birth year; submit renewal application and processing fee.

Official no-examination sources

Effective from 2026-09-22.

Resident individual — prior licensed producer exemption (currently licensed)
No examination is required for this applicant pathway.
Application
Submit the prescribed application and pay the nonrefundable processing fee; attach required background documents.
Board Moving Instruction
The SCC Agents Moving To Virginia page states: "Your resident license in your previous home state must be inactivated to obtain a Virginia resident license." This implementing instruction is retained alongside § 38.2-1817 G, which also permits an applicant currently licensed in the home state.
Character
Good character and a good reputation for honesty; Commission review of background disclosures.
Line Of Authority
Exemption applies only to the same authority previously held.
Minimum Age
At least 18 years of age (§ 38.2-1820 A).
Prior Status
Currently licensed for the same line of authority in the home state.
Resident Fingerprinting
Resident individuals applying for a new licence must provide fingerprints and pay for criminal history checks (§ 38.2-1819 B); current SCC instructions require usable fingerprints no older than 90 days, with the stated currently licensed same-type 12-month exception.

Official no-examination sources

Effective from 2026-09-22.

Resident individual — prior licensed producer exemption (recently cancelled)
No examination is required for this applicant pathway.
Application
Submit the prescribed application and pay the nonrefundable processing fee; attach required background documents.
Board Moving Instruction
The SCC Agents Moving To Virginia page states: "Your resident license in your previous home state must be inactivated to obtain a Virginia resident license." This implementing instruction is retained alongside § 38.2-1817 G, which also permits an applicant currently licensed in the home state.
Character
Good character and a good reputation for honesty; Commission review of background disclosures.
Line Of Authority
Exemption applies only to the same authority previously held.
Minimum Age
At least 18 years of age (§ 38.2-1820 A).
Prior Status
Apply within 90 calendar days after cancellation of the prior home-state licence; good standing at cancellation must be certified by the home state or shown by Producer Database records.
Resident Fingerprinting
Resident individuals applying for a new licence must provide fingerprints and pay for criminal history checks (§ 38.2-1819 B); current SCC instructions require usable fingerprints no older than 90 days, with the stated currently licensed same-type 12-month exception.

Official no-examination sources

Effective from 2026-09-22.

Resident individual — permanent health authority following a temporary licence

At least one of the following alternatives:

Applicant Type
Resident individual without a statutory prelicensing exemption.
Application
Submit the prescribed application and pay the nonrefundable processing fee; attach required background documents.
Appointments
Appointments remain effective if a permanent licence of the same type is obtained before temporary expiry (§ 38.2-1830 E).
Character
Good character and a good reputation for honesty; Commission review of background disclosures.
Examination Choice
Pass Series 11-06 Health, or Series 11-01 Life, Annuities, and Health for both qualifications; these are independently registered official assessments.
Failed Examinations
After three failed attempts, wait 30 calendar days before retaking (§ 38.2-1817 B).
Minimum Age
At least 18 years of age (§ 38.2-1820 A).
Passing Score Window
Obtain the licence within 183 calendar days after passing; otherwise repeat the examination and applicable prelicensing requirements.
Prior Status
Holds a temporary life-and-health or debit-only licence; satisfy the applicable permanent health licensing requirements. A temporary licence is not required before permanent licensing.
Resident Fingerprinting
Resident individuals applying for a new licence must provide fingerprints and pay for criminal history checks (§ 38.2-1819 B); current SCC instructions require usable fingerprints no older than 90 days, with the stated currently licensed same-type 12-month exception.

Virginia Life, Annuities, and Health Insurance Examination

Provider
Prometric
Format
Computer-administered four-option multiple-choice examination
Exam questions
140 scored questions and 10 pretest questions
Time limit
2.5 hours
Exam fee
$35
Examination outline
  • 1.0 Insurance Regulation (10%)
    • 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)) Viatical Settlements (38.2-1865.1; 6000; 14VAC5-71-20) 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) Long-term Care Rate Increases, Notice Requirements (38.2-5206.1)
    • 1.3 Federal regulation Fair Credit Reporting Act (15 USC 1681–1681d) Fraud and false statements (18 USC 1033, 1034) 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 (6%)
    • 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 assessment insurers 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 Life Insurance Basics (6%)
    • 3.1 Insurable interest (38.2-301, 302, 3105)
    • 3.2 Personal uses of life insurance Survivor protection Estate creation Cash accumulation Liquidity Estate conservation
    • 3.3 Determining amount of personal life insurance Human life value approach Needs approach Types of information gathered Determining lump-sum needs Planning for income needs
    • 3.4 Business uses of life insurance Buy-sell funding Key person Executive bonuses
    • 3.5 Classes of life insurance policies Group versus individual Permanent versus term Participating versus nonparticipating Fixed versus variable life insurance and annuities Regulation of variable products ( FINRA and Virginia) (38.2-3113; 14 VAC 5-20-30, 80) Types of variable products
    • 3.6 Premiums Factors in premium determination Mortality Interest Expense Premium concepts Net single premium Gross annual premium Premium payment mode
    • 3.7 Agent responsibilities Rules Governing Advertisement of Life Insurance and Annuities (14VAC 5-41) Solicitation and sales presentations (14 VAC 5-41) Life, Accident and Sickness Insurance Guaranty Association (38.2-1700, 1715) Policy summary Buyer's guide Replacement (14 VAC 5-30-40) Use and disclosure of insurance information (38.2-613) Field underwriting Notice of information practices (38.2-604) Adverse underwriting decisions (38.2-610 – 612) Application procedures Required signatures Changes in the application Consequences of incomplete applications Warranties and representations Collecting the initial premium and issuing the receipt Disclosures at point of sale (e.g., HIPAA, HIV consent) USA PATRIOT Act/anti-money laundering Delivery Policy review Effective date of coverage Premium collection Statement of good health
    • 3.8 Individual underwriting by the insurer Information sources and regulation Application Agent report Attending physician statement Investigative consumer (inspection) report Medical Information Bureau (MIB) Medical examinations and lab tests including HIV (38.2-613.01; 14 VAC 5-180-50) Unfair discrimination (38.2-508; 38.2-508.1; 38.2-508.2) Classification of risks Preferred Standard Substandard Declined
  • 4.0 Life Insurance Policies (10%)
    • 4.1 Term life insurance Level term Annual renewable term Level premium term Decreasing term Increasing term Return of premium
    • 4.2 Whole life insurance Ordinary whole life Continuous premium (straight life) Limited payment Interest sensitive/current assumption Indexed life Equity indexed life Single premium Variable whole life Variable universal life
    • 4.3 Flexible premium policies Adjustable life Universal life
    • 4.4 Specialized policies Joint life (first-to-die) Survivorship life (second-to-die) Juvenile/student life
    • 4.5 Group life insurance Characteristics of group plans Types of eligible groups (38.2-3318.1) Employer/employee Debtor groups Labor union groups Trust Associations Group underwriting requirements Benefit payments (38.2-3330) Covered dependents (38.2-3323) Lives covered (38.2-3322.2) Conversion to individual policy (38.2-3332–3334) Contributory vs. noncontributory
    • 4.6 Credit life insurance (individual versus group)
  • 5.0 Life Insurance Policy Provisions, Options and Riders (11%)
    • 5.1 Standard provisions Ownership Assignment (38.2-3111) Entire contract (38.2-3304) Right to examine (free look) (38.2-3301) Payment of premiums (38.2-3302) Grace period (38.2-3303) Reinstatement (38.2-3311) Incontestability (38.2-3107, 3305) Misstatement of age and misstatement of gender (38.2-3108, 3306) Exclusions Suicide (38.2-3106) War clause Interest on proceeds (38.2-3115) Prohibited provisions including backdating (38.2-3104, 3316)
    • 5.2 Beneficiaries Designation options Individuals Classes Estates Minors Trusts Succession Revocable versus irrevocable Annulment or divorce (38.2-305(C)) Common disaster clause Spendthrift clause
    • 5.3 Settlement options Cash payment Interest only Fixed-period installments Fixed-amount installments Life income Single life Joint and survivor
    • 5.4 Nonforfeiture options Cash surrender value Extended term Reduced paid-up insurance
    • 5.5 Policy loans (38.2-3308) Cash loans Automatic premium loans Withdrawals or partial surrenders Educational loans (38.2-3113.3)
    • 5.6 Dividend options (38.2-3307) Cash payment Reduction of premium payments Accumulation at interest One-year term option Paid-up additions Paid-up insurance
    • 5.7 Disability riders Waiver of premium Waiver of cost of insurance Disability income benefit Payor benefit life/disability (juvenile insurance)
    • 5.8 Accelerated benefit provision/rider Conditions for payment (38.2-3115.1; 14 VAC 5-70-40) Diagnosis of terminal illness Diagnosis of catastrophic illness Permanent confinement Inability to perform ADLs Disclosure (14 VAC 5-70-80) Written disclosure required Effect on death benefit Cash value Loans and loan interest Tax consequences Premium
    • 5.9 Riders covering additional insureds Spouse/other-insured term rider Children's term rider Family term rider
    • 5.10 Riders affecting the death benefit amount Accidental death Guaranteed insurability Cost of living Return of premium
  • 6.0 Annuities (6%)
    • 6.1 Annuity principles and concepts Accumulation period versus annuity period Owner, annuitant and beneficiary Insurance aspects of annuities
    • 6.2 Immediate versus deferred annuities Single premium immediate annuities (SPIAs) Deferred annuities Premium payment options Nonforfeiture Surrender charges Bail-out provisions Death benefits
    • 6.3 Annuity (benefit) payment options Life contingency options Pure life versus life with guaranteed minimum Single life versus multiple life Annuities certain (types)
    • 6.4 Annuity products Fixed annuities General account assets Interest rate guarantees (minimum versus current) Level benefit payment amount Variable Annuities Equity indexed annuities Market value adjusted annuities (modified guaranteed annuities) (38.2-107.1, 3113.1)
    • 6.5 Uses of annuities Lump-sum settlements Qualified retirement plans including group versus individual Personal uses Tax-deferred growth Retirement income Education funds Charitable gift annuity (38.2-106.1, 3113.2) Suitability in Annuity Transactions (14VAC5-45 )
  • 7.0 Federal Tax Considerations for Life Insurance and Annuities (2%)
    • 7.1 Taxation of personal life insurance Amounts available to policyowner Cash value increases Dividends Policy loans Surrenders Amounts received by beneficiary General rule and exceptions Settlement options Values included in insured's estate Cost Recovery Rule
    • 7.2 Modified endowment contracts (MECs) Modified endowment versus life insurance Seven-pay test Distributions
    • 7.3 Taxation of non-qualified annuities Individually-owned Accumulation phase (tax issues related to withdrawals) Annuity phase and the exclusion ratio Distributions at death Corporate-owned
    • 7.4 Taxation of individual retirement accounts (IRAs) Traditional IRAs Contributions and deductible amounts Premature distributions (including taxation issues) Annuity phase benefit payments Values included in the annuitant's estate Amounts received by beneficiary Roth IRAs Contributions and limits Distributions
    • 7.5 Rollovers and transfers (IRAs and qualified plans)
    • 7.6 Section 1035 exchanges
  • 8.0 Qualified Plans (2%)
    • 8.1 General requirements
    • 8.2 Federal tax considerations Tax advantages for employers and employees Taxation of distributions (age-related)
    • 8.3 Plan types, characteristics and purchasers Simplified employee pensions (SEPs) Self-employed plans (HR 10 or Keogh plans) Profit-sharing and 401(k) plans SIMPLE plans 403(b) tax-sheltered annuities (TSAs)
  • 9.0 Health Insurance Basics (6%)
    • 9.1 Definitions of perils Accidental injury Sickness
    • 9.2 Principal types of losses and benefits Loss of income from disability Medical expense Dental expense Long-term care expense
    • 9.3 Classes of health insurance policies Individual versus group Private versus government Limited versus comprehensive
    • 9.4 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
    • 9.5 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
    • 9.6 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 Common situations for errors/omissions Notification of Medicare eligibility
    • 9.7 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
    • 9.8 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)
  • 10.0 Individual Health Insurance Policy General Provisions (11%)
    • 10.1 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
    • 10.2 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 benefits Unpaid premium Cancellation by company Conformity with state statutes Illegal occupation Intoxicants and narcotics
    • 10.3 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, 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)
  • 11.0 Disability Income and Related Insurance (5%)
    • 11.1 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
    • 11.2 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 Coordination with social insurance and workers compensation benefits 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
    • 11.3 Unique aspects of individual disability underwriting Occupational considerations Benefit limits Policy issuance alternatives
    • 11.4 Group disability income insurance Group versus individual plans Short-term disability (STD) Long-term disability (LTD)
    • 11.5 Business disability insurance Key employee (partner) disability income Business overhead expense policy Business Disability buyout policy
    • 11.6 Social Security disability Qualification for disability benefits Definition of disability Waiting period Disability income benefits
    • 11.7 Workers compensation Eligibility Benefits
  • 12.0 Medical Plans (6%)
    • 12.1 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
    • 12.2 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)
    • 12.3 Cost containment in health care delivery Cost-saving services Preventive care Outpatient ambulatory services Alternatives to hospital services Utilization management Prospective review Concurrent review
    • 12.4 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 or physical disability dependent adult coverage (38.2-3409)
    • 12.5 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
    • 12.6 Health Savings Accounts (HSAs) and Health Reimbursement Accounts (HRAs) Definition Eligibility Contribution limits
  • 13.0 Group Health Insurance (5%)
    • 13.1 Characteristics of group insurance Group contract Certificate of coverage (38.2-3533) Experience rating versus community rating
    • 13.2 Defined groups (38.2-3521.1) Employer Creditor Labor union Association Credit union
    • 13.3 Marketing considerations Advertising Regulatory jurisdiction/place of delivery
    • 13.4 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)
    • 13.5 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)
  • 14.0 Dental Insurance (1%)
    • 14.1 Types of dental treatment Diagnostic and preventive Restorative Oral surgery Endodontics Periodontics Prosthodontics Orthodontics
    • 14.2 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
    • 14.3 Employer group dental expense Integrated deductibles versus stand-alone plans Minimizing adverse selection
  • 15.0 Insurance for Senior Citizens and Special Needs Individuals (11%)
    • 15.1 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
    • 15.2 Medicare supplement insurance (14 VAC 5-170-10–220) 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 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))
    • 15.3 Other options for individuals with Medicare Employer group health plans Disabled employees Employees with kidney failure Individuals age 65 and older Medicaid Eligibility Benefits
    • 15.4 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)
  • 16.0 Federal Tax Considerations for Health Insurance (2%)
    • 16.1 Personally-owned health insurance Disability income insurance Medical expense insurance Long-term care insurance
    • 16.2 Employer group health insurance Disability income (STD, LTD) Medical and dental expense Long-term care insurance Accidental death and dismemberment
    • 16.3 Medical expense coverage for sole proprietors and partners
    • 16.4 Business disability insurance Key person disability income Business overhead expense Buy-sell policy
    • 16.5 Health Savings Accounts (HSAs), Health Reimbursement Accounts (HRAs), and Flexible Spending Accounts (FSAs)
Examination sources

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