FL Adjuster Claim Professional Exam: Health Insurance Basics
Fast Facts
Health insurance protects against medical care expenses, covering risks like illness and accidental injury. It is primarily regulated by states, with federal oversight through the Affordable Care Act (ACA).
6 Major Types of Health Insurance Policies
- Medical Expense Insurance: Covers medical care and services, including hospital stays and physician visits.
- Disability Income Insurance: Replaces income lost when a disability prevents the insured from working.
- Long-Term Care Insurance: Covers long-term care in nursing homes, at home, or in extended care facilities.
- Medicare Supplement Insurance: Private coverage to supplement Medicare for those 65 and older.
- Accidental Death and Dismemberment (AD&D) Insurance: Pays a lump-sum benefit if the insured dies or is dismembered due to an accident.
- Limited Benefits Insurance: Covers specific conditions or services, such as dental, vision, or specified disease insurance.
Affordable Care Act (ACA) Key Provisions
- No pre-existing condition limitations for medical insurance policies issued after 2014.
- All medical insurance policies are guaranteed issue.
- Dependent children covered under a parent’s group medical plan until age 26.
- Federal subsidies and Medicaid available for low-income individuals and families.
- Insurance offered at four metal levels: Bronze (60% plan pays), Silver (70%), Gold (80%), Platinum (90%).
- State health insurance exchanges help individuals and small businesses shop for policies.
Providers of Health Insurance
Private Insurance Providers
- Commercial Insurance Companies: Offer traditional indemnity plans that reimburse healthcare costs.
- Health and Managed Care Providers: Provide care through networks of healthcare providers and facilities.
Governmental Insurance Providers
- Medicare: Federal program for hospital and medical insurance for those 65 and older.
- Medicaid: State program (with federal support) for low-income individuals of any age.
- Social Security Disability: Provides income for those under 65 who are totally disabled.
- Workers’ Compensation: Covers job-related illnesses or injuries.
Group vs. Individual Plans
Group Plans: Cover multiple people (e.g., through employers or associations) under a single contract. Each member receives a certificate of coverage.
Individual Plans: Cover an individual or family. Eligible family members include the insured, spouse, and dependent children.
Health Insurance Marketplace
The Health Insurance Marketplace (HealthCare.gov) allows consumers to shop for ACA-compliant plans during the Open Enrollment Period (OEP) (Nov 1–Jan 15) or Special Enrollment Period (SEP) for life events like marriage or job loss.
Essential Health Benefits (EHBs)
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance abuse services
- Prescription drugs
- Rehabilitation services
- Laboratory services
- Preventive and wellness services
- Pediatric services
Metal Levels of Coverage
| Metal Level |
Plan Pays |
Insured Pays |
| Bronze |
60% |
40% |
| Silver |
70% |
30% |
| Gold |
80% |
20% |
| Platinum |
90% |
10% |
Pre-Existing Conditions
Since 2014, ACA-compliant plans cannot deny coverage or charge more for pre-existing conditions. Grandfathered plans (existing before March 23, 2010) may exclude pre-existing conditions for up to 12 months (18 months for late enrollees in group plans).
Test Your Knowledge!
For Your Review
- Health insurance protects against medical expenses from illness or injury.
- Different policies cover specific risks (e.g., disability income, medical expense, AD&D).
- ACA ensures guaranteed issue, no pre-existing condition exclusions, and coverage for dependents until age 26.
- Reimbursement contracts pay based on loss; valued contracts pay a fixed sum.
- Study state-specific regulations for the FL Adjuster Claim Professional Exam.