Colorado Statues Rules and Regulations Common to Life and Sickness and Accident Insurance

Standard appeal

A health carrier must establish written procedures for the review of an adverse determination if the frame of review would not jepordize the health of covered person

Preventative health care screenings

All individual and group health insurance must cover all preventative care: alcohol misuse screening and counseling, cervical cancer screening, breast cancer screening, cholesterol screening, colorectal screening, childhood immunizations, flu immunizations, tobacco use and ceasation

Diabetes

All policies must cover diabetes

Agency contract

An insurer appoints and individual to act on its behalf

Deformation

Any false, maliciously critical or derogatory communication - written or oral- that injuries anothers reputation, fame or character

Exception to license requirements

Any salaried employee who only does clerical work Any salaried employee of a producer who does not write or solicit insurance Anyone who whole sales life insurance and doesn't receive a commissioner fee Anyone who offers their employees insurance involving insurance offered by a licensed insurer Employees of an insurance company who are overseeing the risks, oversights within the insurance but not directly selling insurance Management, partnerships, or corporations that do no solict insurance from the public

Emergency services

Cannot be denied

Individual enrollment plans

Carriers offering individual enrollement plans must accept every individual who applies for coverage May restrict to open enrollment or special enrollment periods Cannot impose preexisting conditions Three month grace period

Market conduct

Combination of compliance and ethics

Compliance

Conducting business in accordance with currrent rules set by governing rules

Utilization Review

Formal technique designed to evaluate the clinical necessity, appropriateness or efficiency of health care services, procedures and settings

Retrospective review determinations

Health carrier must make determination 30 days after

Urgent Care Requests

Health carrier must make the deicision ASAP, no later tahn 72 hours

Notice and disclosure of right external review

Health insurance carrier can notify of right of external review

Adverse determination

If an adverse determination is made during a person's hospital stay, the health care must go on without liability until the covered person is notified

Rebating

If the buyers recieves any part of the producers commission or anything else of significant value

How should insurance producers account for each insurance policy and the premiums they recieve on it?

In a separate insured's account

Controlled business

Insurance written in the licensee's own intrests or spouse or families interest The commissioner with not grant renew of license if this is found

Replacement

Insured needs a Notice Reguarding Replacement of Accident and Health Insurance

Needs selling

Involves problem analysis, action planning, product recommendation, and plan implementation. Important Producer Commitments: 1: to obtain and maintain the knowledge and skills necessary to preform those tasks 2: to educate the client about the products and plans that may be implemented on the producer's recommendation

Triggering event

Must apply within 30 days of trigging even in order to recieve coverage Triggering events are: involuntaring loosing existing coverage, when an individual loses pregnancy related Medicaid coverage, loses a dependent through divorce or legal seperation, gaining an independent through birth or adoption

Continuing Education

Must complete 24 hours every 2 years

Procedures for review decisions

No later than 15 days after procedure

Rebating

Offering benefits or services not specified in the policy

Agency

One of the parties (principal) has authorized the other (producer) to preform certain legally binding acts on behalf of the principal

Required CO records

Operations and management Policyholder services Claims handling Rating and underwriting Advertising, marketing and sales Complaint greviance Producer licensing

Change of Address

Producers must inform commissioner of change of address within 30 days

Home health care

Recieve 60 health care visits a year

Matertinity and newborn coverage

Required by law unless: have fewer than 15 employers, employees that work less than six consective months, or do self pay insurance or supplemental insurance that covers this need

Two forms that many producers use for clients to review are..

The NAIC buyers guide The Policy Summary

Key principals of agency

The acts of the producer (within the scope of the producers authority) are the acts of the principal A contract completed by the producer on the behalf of the principal is a contract of the principal Payments made to the producer on behalf of the principal are the principal's payments Knowledge of the producer reguarding business of the principal is presumped to be knowledge of the principal

Fraternal Benefit Societies

Those who solicit and sell insurance need licensing Those who do NOT: any officer or employee who devotes their time to all other activities except for selling insurance, anyone who sold life insurance with face amount of 50,000 and received no compensation

A company that has not been authorized to operate in Colorado is also known as

a nonadmitted insurer

Colorado has switched to..

a single-producer system Rather than agent and brokers license everyone gets an insurance producers license

Insurance Marketplace Standards Assosication

acted as a watchdog whose members agreed to adhere to certain ethical principals

Misrepresentation

any written or oral statement that does not accurately describe a policy's features, benefits, or coverage

Unfair Trade Practice Acts

created in 1940s to deal with false advertising includes all deceptive and unfair policies

The Compliance and Ethics Forum for Life Insurers

part of IMSA works with regulators and insurers to promote sound ethical practices in the marketplace

Marketing Ethics

regulation of conduct

Utlization review

set of formal techniques that evaluates the clinical neccessity, appropriateness of efficiency of health care services

An insurer is given the power and express authority through to act for the insurer by:

soliciting applications for coverage, describing coverage and policies to prospects and appliciants and explaining how such policies can be purchased, collecting premiums, providing service to prospects and the insurer's policyholders

An insurance producer is someone who:

solicts, negotiates, effects, procures, delivers, renews, continues or binds: insurance policies of risks located in colorado membership in certain healthcare prepayment plans membership enrollement in certain health plans

Fuduciary

someone whose position and responsibilities involve a high degree of confidence

Ethics

standards of moral behavior

Commissioner of insurance reports a violation of insurance law to

the district attorney

Twisting

unethical act of persuading a policyowner to drop a policy solely for the purpose of selling another policy without regard to possible disadvantages to the policyowner