Enter the world of Health insurance. Sometimes on your exam it will be called disability insurance or coverage. You will need to know the concepts and terminology to pass your exam.
In most states, you will need 70% to pass your exam. That’s basically a “C-“. Don’t take it lightly, the exam makes good use of a thesaurus and also double negatives in their questions which makes it a bit tricky. So sometimes what you have studied and what you see on your exam are quite different. That’s where my materials will help you out. My questions are similar in degree of difficulty and the terminology is similar to what you will see.
The Accident and Health Insurance Exam Curriculum is designed for individuals seeking a license to sell accident and health insurance products. This curriculum focuses specifically on health and accident insurance policies, covering both individual and group markets, and includes state-specific regulatory requirements.
Accident and Health Insurance Exam Curriculum
1. General Insurance Principles
- Insurance Basics
- Risk management concepts: Types of risks (pure vs. speculative), handling risk
- Elements of a legal contract: Offer, acceptance, consideration, legal purpose
- Characteristics of insurance contracts: Adhesion, aleatory, unilateral, conditional
- Insurance Regulation
- Role of state Departments of Insurance
- Federal laws impacting health insurance (e.g., ACA, COBRA, HIPAA)
- Consumer protections: Unfair trade practices and claims handling
- Key Insurance Terms
- Indemnity, premium, underwriting, adverse selection, reinsurance
2. Individual Health Insurance Policies
- Types of Policies
- Medical expense insurance (major medical, basic hospital, surgical, physician)
- Disability income insurance
- Accidental death and dismemberment (AD&D)
- Long-term care insurance
- Critical illness and specified disease policies
- Policy Provisions
- Entire contract, time limit on certain defenses, grace period
- Reinstatement, notice of claim, proof of loss, time of payment of claims
- Legal actions and misstatement of age
- Policy Options and Riders
- Guaranteed insurability, waiver of premium, cost of living adjustment
- Return of premium, inflation protection
- Policy Exclusions
- Pre-existing conditions, war, elective cosmetic surgery, intentional self-harm
3. Group Health Insurance
- Types of Plans
- Fully insured group health plans
- Self-insured plans
- Small vs. large group health plans
- Key Features
- Eligibility requirements, probationary periods, open enrollment
- Coordination of benefits
- Federal Mandates
- Affordable Care Act (ACA): Essential health benefits, preventive care, minimum value
- COBRA continuation coverage
- HIPAA portability and privacy
- Conversion Privileges
- Moving from group to individual coverage
4. Managed Care Plans
- Types of Plans
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Exclusive Provider Organizations (EPOs)
- Point-of-Service Plans (POS)
- Plan Features
- Gatekeeper concept, referral requirements
- Network coverage vs. out-of-network
- Cost-containment strategies: Preauthorization, case management
5. Disability Income Insurance
- Policy Features
- Definition of disability: Own occupation vs. any occupation
- Elimination period, benefit period, and amount
- Partial disability and residual disability benefits
- Additional Riders
- Cost-of-living adjustment, future increase options, waiver of premium
- Taxation of Benefits
- Employer-paid vs. individual policies
- Underwriting Considerations
- Occupation class, income verification, pre-existing conditions
6. Long-Term Care Insurance
- Policy Coverage
- Levels of care: Skilled nursing, intermediate care, custodial care
- Home health care, hospice care, respite care
- Eligibility for benefits: Activities of daily living (ADLs), cognitive impairment
- Policy Provisions
- Elimination period, benefit period, inflation protection
- Partnership programs
- State and Federal Regulations
- Tax-qualified policies
- Medicaid and long-term care planning
7. Medicare and Medicaid
- Medicare
- Parts A, B, C (Medicare Advantage), D (prescription drug plans)
- Medigap policies (Standardized plans)
- Medicaid
- Eligibility and benefits
- Dual eligibility for Medicare and Medicaid
- Federal and State Programs
- CHIP (Children’s Health Insurance Program)
- State-specific Medicaid expansion under ACA
8. Accident Insurance
- Policy Coverage
- Accidental death, dismemberment, and disability
- Accident medical expense coverage
- Policy Features
- Lump-sum vs. scheduled benefits
- Coverage exclusions and limitations
9. Ethics and Market Conduct
- Suitability of Products
- Needs-based selling, matching coverage to client needs
- Disclosures and transparency
- Prohibited Practices
- Misrepresentation, rebating, twisting
- Consumer Protections
- Privacy rules under HIPAA
- Fair claims handling standards
10. State-Specific Laws and Regulations
- Licensing Requirements
- Pre-licensing education hours and examination
- Continuing education requirements (e.g., ethics or long-term care training)
- Mandated Benefits
- State-specific requirements for health insurance benefits (e.g., mental health parity, infertility treatment)
- Claims Handling Standards
- Timeframes for claims acknowledgment and payment
- State-Specific Programs
- High-risk pools, state Medicaid variations