Ch. 7 Colorado Statutes, Rules, and Regulations for Sickness & Accident Insurance Only (2022)

GROUP COVERAGE: Required Features and Benefits

- Continuation of coverage: convert to individual after termination of employment Benefits - Maternity benefits - Mental health benefits

GROUP COVERAGE: Small Groups

- For employers with no more than 50 employees - Coverage must be guaranteed renewable - Open enrollment and special enrollment periods

Any such Hospice and Home Health Care policy must provide a benefit of at least $150 per day for any combination of the following routine home care services:

- Intermittent and 24 hour on-call professional nursing services provided by a registered nurse; - Intermittent and 24 hour on-call social or counseling services; and - Certified nurse aide services (or nursing services delegated to other persons).

INDIVIDUAL INSURANCE: Replacement

- Notice Regarding Replacement - Producer's duties to the applicant and the insurer - Record keeping requirements

Medicare Supplement Plans

- Outline of Coverage - 30-day free-look period - Pre-existing condition exclusion: no more than 6 months - Coverage must be guaranteed renewable

Long-Term Care

- Shopper's Guide and Outline of Coverage - 30-day free-look period - Pre-existing condition exclusion: within 6 months preceding the effective date of coverage of an insured person - Coverage must be guaranteed renewable - Inflation protection - Producer training required (initial and ongoing)

A health coverage plan will not make a determination that it will deny a request for benefits for a covered individual on grounds that such treatment of covered benefit is not medically nescessary unless such denial is made according to procedure

-Signature of a licensed physician familiar with standards of care in Colorado if denial is based on benefits not medically necessary -The specific reasons for the adverse determination -an explanation of the specific medical basis for the denial

The carrier must identify the claim as "received" within

10 business days after the submission of the claim. The claim must be deemed received on the date it is listed on the notification mechanism by the carrier.

A certified early intervention service broker will notify the insurer within

10 days of determining that a child (up to age 3) is eligible for early intervention services.

The employer must notify the employee in writing of the employee's right to continue health care coverage upon termination from employment. A written communication signed by the employee or a notice postmarked within

10 days of termination mailed by the employer to the last-known address of the employee will meet the notice requirements.

Insurers must determine coverage and notify the covered person and the covered person's facility and/or health care professional of the determination within __________ of the insurer's receipt of the request.

15 calendar days

insurers must provide health insurance claim forms within how many days?

15 days

Upon the termination of employment of an eligible employee, the death of any employee, or the change in marital status of any employee, the employee or dependent has the right to continue the coverage for a period of

18 months after loss of coverage or until the employee or dependent becomes eligible for other group coverage, whichever occurs first. However, should new coverage exclude a condition covered under the continued plan, coverage under the prior employer's plan may be continued for the excluded condition only for the 18 months or until the new plan covers the condition, whichever occurs first.

health insurance policies become incontestable after what time period from the poilicy issue?

2 years

in colorado, long term care insurance policies must pay for benefits if a patient cannot perform how many activities of daily living?

3

All individual and small employer health benefit plans, how long is the grace period for persons receiving the federal advance payment tax credit?

3 months

Max age for catastrophic plan?

30

Clean claims must be paid, denied, or settled within

30 calendar days after receipt by the carrier if submitted electronically, and within 45 calendar days after receipt by the carrier if submitted by any other means.

If the resolution of a claim requires additional information, the carrier must make the specific request in writing within

30 calendar days after receipt of the claim. The person receiving a request for such additional information must submit all additional information requested by the carrier within 30 calendar days after receipt of request.

Insurers must pay benefits into a trust established by the Colorado Department of Human Services (CDHS) within

30 days of receipt of an invoice issued by CDHS.

Policy Termination

30 days' notice

If the insureds are not receiving a subsidy under the federal act, the policies must have a ______ grace period for the payment of any premium due, other than the first premium.

31-day

a covered individual requesting an independent external review will make a request within _ months after receiving notification of denial of coverage

4

A covered individual may request an independent external review within how long after receiving notification of a denial of coverage?

4 months

When a testimonial refers to benefits received under an accident and sickness insurance policy, the specific claim data, including claim number, date of loss and other pertinent information must be retained by the insurer for inspection for a period of

4 years or until the filing of the next regular report of examination of the insurer, whichever is the longer period of time.

Coverage of hearing aids replacement are covered every

5 years

Producers are required to list any other accident and sickness insurance they have sold to the applicant, including policies that are still in force and those sold in the past *** Rule applies to individual accident and sickness insurance. It does NOT apply to Medicare supplement insurance, conversion to an individual or family policy from a group, blanket or group type policy.***

5 years which are no longer in force

From age 61 to 75, inflation protection must be at least

5% simple interest, 3% compound interest, CPI or 5% compounded 2 times max. From age 76 on, no inflation is required but still may be purchased as part of the policy.

When can an insured initiate legal action against the insurer?

60 days after submitting proof of loss

Carriers must establish a special enrollment period of

60 days for individuals who experience triggering events

A small employer carrier may vary the application of minimum participation requirements and minimum employer contribution requirements only by the size of the small employer group. However, there cannot be a waiting period of more than

90 days

In accident and health polices insured in this state, an insured must submit proof of loss within how many days?

90 days

In accident and health policies issued in this state, an insured must submit proof of loss within how many days?

90 days

The Division for Developmental Disabilities will notify the insurer within how many if a child is no longer eligible for early intervention services?

90 days

All claims must be paid, denied or settled within

90 days after receipt

Absent fraud, all other claims must be paid, denied, or settled within

90 days after receipt by the carrier. A carrier that fails to pay, deny, or settle a claim within 90 days after receiving the claim must pay to the insured or health care provider a penalty in an amount equal to 20% of the total amount ultimately allowed on the claim.

Hospice care is limited to

90 days; at least $150 per day

The outline of coverage must follow the format and content prescribed by the Commissioner. The outline of coverage must include the following:

A description of the principal benefits and coverage provided in the policy; A statement of the exceptions, reductions, and limitations contained in the policy; A statement of the renewal provisions, including any reservation by the insurer of a right to change premiums; and A statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.

Which of the following is not required to be covered by sickness and accident insurance policies issued in the state of Colorado?

A mom's broken arm

Time limit on certain defenses

After 2 years from the date of issue of a policy, no misstatements made by the applicant in the policy application (except in the cases of fraud) can be used to void the policy or to deny a claim for loss incurred or disability beginning after the expiration of a 2-year period.

If a claim is denied, the insurer must notify the covered person and provide

An explanation of the specific medical basis for the adverse determination; The specific reason or reasons for the adverse determination; Reference to the specific policy provisions on which the determination is based; A description of any additional material or information necessary for the covered person to perfect the benefit request, including an explanation of why the material or information is necessary to perfect the request; If the insurer relied upon an internal rule, guideline, protocol, or other similar criterion to make the adverse determination, that information must be disclosed, and the insurer must provide any of those upon request from the covered person; If the adverse determination is based on a medical necessity or similar exclusion or limitation, either an explanation of the scientific or clinical judgment for making the determination, applying the terms of the long-term care policy to the covered person's medical circumstances or a statement that an explanation will be provided to the covered person free of charge upon request; Information sufficient for the covered person to be able to identify the claim involved and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning; A description of the insurer's review procedures and the time limits applicable to such procedures; and An explanation of the right of the covered person to appeal an initial adverse determination with a description of the procedures for requesting an appeal.

All denials of requests for reimbursement for medical treatment, standing referrals, or other benefits must include the following information:

An explanation of the specific medical basis for the denial; The specific reasons for the adverse determination; Reference to the specific health coverage plan provisions on which the determination is based; A description of the health coverage plan's review procedures and the time limits applicable to such procedures and will also advise the covered person and the covered person's designated representative of the right to appeal an adverse decision; Signature of a licensed physician familiar with standards of care in Colorado if denial is based on benefits not medically necessary or appropriate; and Notification of the person's right to an independent external review.

Some of the triggering events for special enrollment in health plans issued in Colorado

An individual or his or her dependent involuntarily loses existing creditable coverage for any reason other than fraud, misrepresentation, or failure to pay a premium. An individual loses pregnancy-related Medicare coverage. An Exchange enrollee loses a dependent or is no longer considered a dependent through divorce or legal separation. An individual gains a dependent or becomes a dependent through marriage, civil union, birth, adoption, or placement in foster care. An individual gains access to other creditable coverage as a result of a permanent change in residence. Native Americans may enroll in a qualified health plan or change from one qualified health plan to another one time per month.

Carriers that offer behavioral, mental health, and substance use disorder treatment must also cover

An unhealthy alcohol use screening for adults, which must be provided without deductibles, copayments or coinsurance; A preventive screening for depression in adolescents and adults, which must be provided without deductibles, copayments or coinsurance; and Perinatal maternal counseling for persons at risk, which must be provided without deductibles, copayments or coinsurance.

small employer

Any person, firm, corporation, partnership, or association that is actively engaged in business and has 50 employees or less.

Benefit levels for home health care services cannot be less than the deductible, coinsurance and stop loss provisions of the overall policy. The following are required benefits:

At least 60 home health visits in any calendar year; Skilled nursing services provided by a registered or licensed nurse; Certified nurse aide services; Physical therapy; Occupational therapy; Speech and language therapy; Respiratory and inhalation therapy; Nutrition counseling by a nutritionist or dietitian; Social work practice services; Medical supplies; Prosthesis and orthopedic appliances; and Rental or purchase of durable medical equipment.

A long-term care insurance policy must condition the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment. Eligibility for the payment of benefits will not be more restrictive than requiring either a deficiency in the ability to perform no more than 3 of the activities of daily living or the presence of cognitive impairment. Activities of daily living will include the following:

Bathing; Continence; Dressing; Eating; Toileting; and Transferring.

metal levels

Bronze 60% Silver 70% Gold 80% Platinum 90%

which of the following is defined as the demographic characteristics that carriers consider when determining premium rates for individual and small employers?

Case characteristics

All carriers that issue health benefit plan coverage or Medicare Supplemental coverage in this state must provide a

Colorado health benefit plan description form for each policy, contract, and plan of health benefits that either covers a Colorado resident or is marketed to a Colorado resident.

January 1 for health benefit plans purchased on or before

December 15 of the open enrollment period

February 1 for health benefit plans purchased between

December 16 through January 15 of the open enrollment period

This time limit may be extended once for up to 15 days provided the insurer

Determines that an extension is necessary due to matters beyond the insurer's control; and Notifies the covered person BEFORE the expiration of the initial 15 calendar day time period of the circumstances requiring the extension of time and the date by which the insurer expects to make a determination.

To comply with the fair marketing standards for insurers in this state, insurers or producers may NOT do any of the following:

Discourage individuals or small employers from filing an application for health coverage because of the health status, claims experience, industry, occupation, or geographic location; Directly or indirectly enter into any contract, agreement, or arrangement with a producer that provides for or results in the compensation paid to a producer for the sale of a health benefit plan to be varied because of the health status, claims experience, industry, occupation, or geographic location of the small employer; For smaller group carriers: terminate, fail to renew, or limit contract or agreement of representation with a producer for any reason related to the health status, claims experience, occupation, or geographic area of the small employers placed by the producer with the small employer carrier; Induce or otherwise encourage a small employer to exclude an employee from health coverage or benefits provided in connection with the employee's employment.

Every insurer, health care service plan or other entity marketing long-term care insurance coverage in this state, directly or through its producers, must do the following:

Establish marketing procedures to assure that any comparison of policies by its producers will be fair and accurate Establish marketing procedures to avoid excessive sales of insurance Display prominently by type, stamp or other appropriate means, on the first page of the outline of coverage and policy, "Notice to buyer: This policy may not cover all of the costs associated with long-term care incurred by the buyer during the period of coverage. The buyer is advised to review carefully all policy limitations." Inquire and otherwise make every reasonable effort to identify whether a prospective applicant for LTC insurance already has accident and sickness or long-term care insurance, and the types and amounts of any such coverage At solicitation, provide written notice to the prospective policyholder and certificate holder that a senior insurance counseling program approved by the Commissioner is available, and the name, address and telephone number of the program Use the terms "noncancellable" or "level premium" only when the policy or certificate conforms to approved definitions

Reinstatement

If any renewal premium is not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or its producer, without requiring an application for reinstatement, will reinstate the policy. If the insurer or producer requires an application for reinstatement and issues a conditional receipt for the premium received, the policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the 45 day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application.

Grace period

In policies other than health benefit plans, 7 days for weekly premium policies, 10 days for monthly premium policies, and 31 days for all other modes will be granted for the payment of each premium falling due after the first premium. The policy will continue in force during the grace period. (see additional grace period requirements for individual and small employer plans below)

The inflation protection feature may be no less favorable than one of the following:

Increases benefit levels annually; Guarantees the insured individual the right to periodically increase benefit levels without providing evidence of insurability or health status so long as the option for the previous period has not been declined; or Covers a specified percentage of actual or reasonable charges.

Time of payment of claims

Indemnities payable under this policy for any loss will be paid immediately upon receipt of due written proof of such loss.

The benefits available to newborn children must consist of coverage for what and how long?

Injury or sickness, including all medically necessary care and treatment of medically diagnosed congenital defects and birth abnormalities for the first 31 days of the newborn's life.

March 1 for health benefit plans purchased between

January 16 through January 31 of the open enrollment period

Coverage for a hospital stay following a normal vaginal delivery must not be limited to how long?

Less than 48 hours

Coverage for a hospital stay following a cesarean section must not be limited to how long?

Less than 96 hours

The total benefit for each Hospice and Home Health Care benefit period for these services cannot be

Less than the per diem benefit, multiplied by 90 days

Under the guaranteed renewability rider, for which of the following reasons may an insurance company non renew a health benefit plan?

Material misrepresentation

in regards to biological based mental illness and metal disorders group health policies in co

Must provide the same coverage that is provided for physical illness

Legal actions

No action at law will be brought to recover on a policy prior to the expiration of 60 days after written proof of loss has been furnished. No such action will be brought after the expiration of 3 years after the time written proof of loss is required to be furnished.

A carrier providing coverage under a health benefit plan cannot discontinue or refuse to renew coverage except for the following reasons:

Nonpayment of premium; Fraud or intentional misrepresentation of material fact; Discontinuing or nonrenewal of all individual and group plans by the insurer. The Commissioner must be notified of discontinuation at least 180 days in advance; notice to the Commissioner must be provided at least 3 working days prior to the notice to the affected individuals; If the Commissioner finds that the continuation of the coverage would not be in the best interest of the policyholders or certificate holders; the plan is obsolete, or would impair the carrier's ability to meet its contractual obligations. Once the Commissioner has made such a finding, the carrier must provide notice to each covered individual of discontinuation at least 90 days prior to the date of discontinuation, and give each affected covered individual the opportunity to purchase any other individual health insurance coverage offered by the carrier. The carrier will be prohibited from writing new health benefit plans of the same type as was discontinued for a period of 5 years from the date of the notice to the insurance Commissioner; If the policyholder of a group plan fails to comply with participation or contribution rules; or With respect to small group health benefit plans, an employer is no longer actively engaged in the business in which it was engaged on the effective date of the plan.

Upon determining that a sale will involve replacement of accident and sickness insurance, any issuer, other than a direct response issuer, will furnish the applicant, prior to issuance or delivery of the accident and sickness insurance policy or contract, a *** Rule applies to individual accident and sickness insurance. It does NOT apply to Medicare supplement insurance, conversion to an individual or family policy from a group, blanket or group type policy.***

Notice Regarding Replacement (in the format prescribed by the Commissioner) of accident and sickness insurance, as well as the following: A copy of such notice signed by the applicant and producer will be provided to the applicant; An additional signed copy will be retained by the issuer; and A direct response issuer must deliver to the applicant, at the time of issuance of the policy, The Notice to Applicant Regarding Replacement of Accident and Sickness Insurance.

before a carrier can offer health benefit plan to small employers what must be filed?

Notice of intent

The open enrollment period for plans effective on or after January 1 must begin on

November 1 of the previous year and extend through January 31 of the year of coverage.

The annual open enrollment period begins

October 15 and extends through December 7 of the preceding calendar year.

PPACA

Patient Protection and Affordable Care Act: mandates health care services for all eligible us citizens and nationals

Which of the following provisions is mandatory for health insurance policies?

Physical examination and autopsy

an insurance producer soliciting application for long-term care insurance policies must deliver the shopper guide?

Prior to the presentation of an application

The purpose of the Long-term Care (LTC) Insurance Act is to do the following:

Promote the public interest and the availability of LTC insurance policies; Protect applicants for long-term care insurance from unfair or deceptive sales or enrollment practices; Establish standards for LTC insurance; Facilitate public understanding and comparison of policies; and Facilitate flexibility and innovation in the development of LTC insurance coverage.

A health coverage plan will not make a determination that will deny a request for benefits for a covered individual on grounds that such treatment of covered benefits is not medically necessary unless such denial is made according to procedure

Signature of licensed physician familiar with standards of care in CO if denial is based on benefits not medically necessary. -the specific reasons for the adverse determination -an explanation of the specific medical basis for the denial.

If an extension is necessary due to the failure of the covered person to submit necessary information, the notice of extension must

Specifically describe the required information necessary to complete the request; and Give the covered person at least 45 calendar days from the date of receipt of a notice to provide the specified information.

Long-term care insurance topics that need to be covered in training include

State and federal regulations Qualified state LTC programs and relationships with Public and private coverage, including Medicaid LTC services and providers, and changes to those Alternatives to private long-term care insurance Inflation and the importance of inflation protection Consumer suitability.

Colorado law defines case characteristics as demographic characteristics that carriers consider when determining premium rates for individuals and small employers. Case characteristics are limited to the following demographic characteristics:

The age of covered individuals; Geographic location of the policyholder; Family size; and Tobacco use.

Entire contract/changes

The policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. Policy changes will not be valid until approved by an executive officer of the insurer and unless such approval be endorsed or attached. Producers have no authority to change the policy or to waive any of its provisions.

Insurers marketing long-term care insurance and Medicare supplement insurance must establish marketing procedures that ensure that

Their producers' marketing activities are fair and accurate; and Excessive insurance is not sold or issued.

which of the following statements I true regarding deductibles and coinsurance for treatment of mental illness?

They may not differ from those established for other conditions

Change of beneficiary

Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries will not be required to surrender, make any change of beneficiary or beneficiaries, or to any other changes in this policy.

Claim forms

Upon receipt of a notice of claim, the insurer must furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice, the claimant will be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character, and the extent of the loss for which claim is made.

Notice of claim

Written notice of claim must be given to the insurer within 20 days after the occurrence of any loss covered by the policy or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to any authorized producer of the insurer will be deemed notice to the insurer.

Proofs of loss

Written proof of loss must be furnished to the insurer within 90 days after the date of such loss.

Small employer carriers must actively offer to small employers the choice of

a basic health benefit plan or a standard health benefit plan.

Any carrier or any producer who violates any requirement of Colorado law relating to the regulation of long-term care insurance or the marketing of such insurance will be subject to

a fine of up to 3 times the amount of any commissions paid for each policy involved in the violation or up to $10,000, whichever is greater.

Producers who want to market long-term care (LTC) insurance must be licensed as a producer for accident and health or sickness, or life insurance, and must complete

a one-time 16-hour training course, 8 hours of which must be specific to long- term care partnerships, and must be completed in a classroom setting. Additionally, the producer must take a continuing education course of at least 5 hours in a classroom setting every 24 months. Long-term care continuing education may be approved for the producer's license continuing education requirement.

Suitability

a requirement to determine if an insurance product is appropriate for a customer

Small employer carriers apply rating factors such as

age, geographic area, and family composition, consistent with respect to all small employers.

30 day free look policy

all the policyholder a period of time to examine the policy to ascertain if that meets their needs

10 essential benefits of Affordable Care Act

ambulatory services emergency hospitalization maternial and newborn care mental health and substance abuse care prescription drugs rehab chronic disease management pediatric services and oral and vision care

With the exception of supplemental policies covering a specified disease or other limited benefit, all other policies must provide coverage for routine and certain diagnostic screening by low-dose mammography for the presence of breast cancer in adult women. All individual and group sickness and accident insurance policies must cover

an annual breast cancer screening with mammography for all individuals possessing at least one risk factor, including a family history of breast cancer, being 40 years of age or older, or a genetic predisposition to breast cancer.

Solicitation

an attempt to persuade a person to buy an insurance policy, and it can be done orally or in writing

A carrier providing coverage under a health benefit plan can discontiue coverage or refuse to renew such plan for all of the following except

an inordinate number of claims made

A claim requiring additional information is considered

an unclean claim.

Failure to comply with the replacement regulations rules constitutes

an unfair method of competition and an unfair or deceptive act or practice in the business of insurance, which is prohibited. Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of fines and suspension or revocation of license.

In the case of direct response solicitations, the shopper's guide must be presented together with

any application or enrollment form.

Complications of pregnancy — provide coverage for a sickness or disease which is a complication of pregnancy or childbirth in the same manner as

any other similar sickness or disease is otherwise covered under the policy.

Carriers offering individual health benefit plans must accept every eligible individual who

applies for coverage and who agrees to make the required premium payments and abide by the reasonable provisions of the plan. However, carriers may choose to restrict enrollment to open or special enrollment periods.

When a small employer carrier takes case characteristics into consideration the carrier is

applying rsting factors

all sickness and accident insurance issued in state of Colorado must include

availability of coverage for alcoholism child heath supervision hospitalization and general anesthesia for dependent children prosthetic devices cervical cancer vaccines hearing aids for children

To be classified as a clean claim a claim must?

be submitted on the uniform claim form with all fields completed with correct information

The benefit year for individual health benefit plans purchased during the annual open enrollment period is a

calendar year

which of the following is defined as the demographic characteristics that carriers consider when determining premium rates for individuals and small employers?

case characteristics

Clean claim

claim for payment of health care expense that is submitted to a carrier on the uniform claim

If a company uses testimonials or endorsements in its advertisements for more than 1 year, it must obtain a

confirmation

In 2008, Colorado began to allow insurers to sell qualified LTC Partnership (LTCP) policies. These new policies are an alliance between the private insurance industry and the state that allows residents to plan for long-term care needs without depleting all of their assets to pay for care. For every dollar that an LTC Partnership insurance policy pays out in benefits, a

dollar of personal assets can be protected (disregarded during the eligibility review and at estate recovery) if a resident applies for Medicaid. A non-partnership long-term care policy may be exchanged for a LTCP policy.

Hearing aids do not meet the traditional definition of

durable medical equipment; therefore, any benefits paid for a minor child's hearing aid(s) will not be used to exhaust a health benefit plan's durable medical equipment maximum coverage.

Each insurer must maintain at its home or principal office a complete file containing every printed, published or prepared advertisement of any of its policies for a period of

either 4 years of until the filing of the next regular report on examination of the insurer, whichever is the longer period of time.

A carrier is required to establish a mechanism available to providers that enable a provider to confirm the receipt of a claim in a manner other than

electronically

High pressure tactics (prohibited)

employing any method of marketing having the effect of or tending to induce the purchase of insurance through force, fright, threat, whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance.

coverage for diabetes must include

equipement, supplies and outpatient self management training and education

when rating small employer group, small employer carriers may use all of the following factors except

gender

Insurers must offer to each policyholder, at the time of purchase, the option to purchase a policy with an

inflation protection feature

Like all LTC policies, partnership policies must include

inflation protection. The inflation protection must be at least 5% compounded annually or, in the alternative, consumer price indexed inflation protection compounded annually up to age 61.

A carrier that fails to pay, deny or settle a claim within the allotted time periods will be liable for the covered benefits and in addition will pay to the insured

interest at the rate of 20% annually

Twisting (prohibited)

knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or insurers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on or convert any insurance policy or to take out a policy of insurance with another insurer.

Cold lead advertising (prohibited)

making use directly or indirectly of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance producer or insurance company.

Health policies must provide coverage for annual prostate cancer screening for the early detection of prostate cancer in what age(s) of men?

men over the age of 50 years old, and in men over the age of 40 who are in high-risk categories.

under the affordable care act, which classification applies to health plans based on the amount of covered cost?

metal level classification

If payment of a specific premium is required to provide coverage for a child, the policy may require that

notification of birth of the newborn child and payment of the required premium must be furnished to the insurer within 31 days after the date of birth in order to have the coverage continue beyond such 31-day period.

Carriers

organization that process claims that are submitted by doctors and suppliers under medicare

An _________ must be delivered to a prospective applicant for long-term care insurance at the time of initial solicitation through means that prominently direct the attention of the recipient to the document and its purpose.

outline of coverage

which of the following factors would be an underwriting consideration for a small employer carrier?

percentage of participation by the employees

Prostate cancer screening coverage cannot be subject to

policy deductibles, and must be the lesser of $65 per screening or the actual charge. Such benefit will in no way diminish or limit diagnostic benefits otherwise allowable under a policy.

The term "mental disorder" includes

posttraumatic stress disorder, drug and alcohol disorders, dysthymia, cyclothymia, social phobia, agoraphobia with panic disorder, and general anxiety disorder. It also includes out-patient, day treatment and in- patient treatment of anorexia nervosa and bulimia nervosa.

The insurer may adopt standards and criteria for eligibility to be applied to home health services programs and hospice care programs consistent with standards established in

rules and regulations of the Department of Public Health and Environment.

The term "biologically based mental illness" includes

schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder.

Dependent

someone relying on the insured for support

non-renew

terminate an insurance policy at its expiration date

which of the following is required provision for a group accident and health policies?

terminated employees may continue coverage in the group for up to 18 months

Whether an advertisement has a capacity or tendency to mislead or deceive will be determined by

the Commissioner

Coverage for breast cancer screening must cover

the actual charge for the screening. Note that annual mammography screening is considered a preventive service, and therefore, is not subject to policy deductibles, copayments, or coinsurance.

rating factors DO NOT reflect differences due to the nature of the groups assumed to select particular health plans rating factors DO produce premiums for identical groups that differ only by?

the amount of the plan design

long term cost will be printed on

the first page outline of coverage

Coverage for hearing aids includes

the initial assessment, fitting, adjustments, and the required auditory training

In order to provide for full and fair disclosure in the sale of Medicare supplement policies, no individual Medicare supplement policy or certificate will be delivered or issued for delivery in this state unless

the outline of coverage is delivered to the applicant at the time of application.

diabetic benefits

the same annual deductibles and copayments established for all other covered benefits within a given policy. Insurers providing coverage for prescription insulin drugs cannot require an insured to pay more than $100 for a 30-day supply, regardless of the amount or type of insulin needed to fill the covered person's prescription.

When in hospice care, a patient is assumed to be in

the terminal stage of an illness, and is expected to live 6 months or less.

what is the purpose of the replacement regulation that applies to accident and sickness insurance polices in this state?

to protect the interest of policy owners and help them make informed decisions about replacements

What is the purpose of the replacement regulation that applies to accident and sickness insurance policies in this state?

to protect the interest of policy owners and help them make informed decisions about the replacement

T/F all health insurance policies or plans must offer to the policyholder the opportunity to purchase coverage for benefits for the cost of home health services and hospice care which have been recommended by a physician as medically necessary.

true

10,000 fine

violation of long term care insurance

Following a denial of a request for benefits by the health coverage plan, each plan will notify the covered person in

writing