LAH - Chapter 18 SPECIAL**

the marketing of MEdicare Supplement is regulated to prevent

sales of excessive insurance, inaccurate policy comparisons, and the failure to display notice of limitation to the buyer

community rating of policies

1 insures may use separate community rates for different geographic regions, if approved by the Superintendent 2. an insurer must accept an individual or member of a small group for coverage at any time throughout the year for health insurance coverage the insurer offers

a policyholder is entitled to the following grace periods following the premium date, during which the policy remains in force:

1. at least days for policies with premiums that are due weekly 2. at least 10 days for policies with premiums that are due monthly 3. at least 31 days for all other policies

Cancellation by the insured - if an insured changes occupation to a less hazardous one than stated in the policy, the insured can, upon written request, either:

1. cancel policy and receive a refund of the unearned premium 2. reduce the premium accordingly and refund prorated unearned premium from the date of change

conversion privilege - an employee's former spouse and dependent children also have the right to convert group coverage to an individual health insurance policy, if

1. coverage ends due to death 2. divorce or annulment 3. reaching the limiting age stated in the policy

ads must disclose a policy's provisions relating to

1. renewability, 2. cancelability, 3. termination, and 4. changes in benefits 5. losses covered 6. or premiums because of age or other reasons

the open enrollment period for Medicare (and Medicare Supplements) begin

3 months before your 65th birthday and last for 7 months

Free-look period for Medicare Supplement is

30 days

conversion privilege - the person must apply for this individual policy and pay the initial premium within

45 days of leaving the group plan

(Medicare Supplement) All Medicare benefits are entitled to a

6 month open enrollment period beginning on the date they first enroll for benefits under Medicare Part B

an insurer may exclude coverage for preexisting condition on a Medicare Supplement Policy for up to

6 months

limits and exclusions may be placed on: pre-existing conditions or diseases for up to

6 months after the effective date of coverage (a pre-existing condition being one for which medical advice was given or treatment was recommended by or received from a licensed health care provider within 6 months before the effective date of coverage)

A Medicare Supplement policy must be delivered to an applicant with

7 days after producer has received it for delivery

Right to examine (free-look)

Health insurance policies must provide a minimum free-look period of 10 days upon policy delivery this allows the policyowner time to decide whether or not to keep it if the policyowner decides not to keep the policy within the 10 days allowed, a full refund will be given *a policy that is sold by mail must contain a 30-day-free look period

New York tax credit

New York allows gives favorable tax treatment to the premiums paid for tax-qualified long term care policies that meet the state's minimum standards specifically, a policyowner can take an income tax credit equal to 20 percent of the premium paid during the year for LTC insurance if the amount of the credit exceeds the amount of taxpayer owes, the excess may be carried forward to the following year

ads cannot imply that applicants will

become members under a group policy and enjoy special rates or underwriting privileges, unless that is true

mental or nervous disorders may be place on limits and exclusions, although

benefit cant be excluded or limited for Alzheimer's disease or organic brain disease

activities of daily living (ADLs)

considered the basic tasks of everyday life, such as dressing, eating, bathing, mobility *the inability to perform activities of daily living and the impairment of cognitive ability are used to determine eligibility for long term care

pre-existing condition, replacement policies (2) - an individual's waiting period for pre-existing conditions is reduced when he or she has "creditable coverage"

creditable coverage is previous coverage under another group or individual health plan when there has not been a break in coverage of 63 days the 63-day period begins when the individual's previous coverage ended its ends when coverage under your plan begins, or, if earlier, when your group's waiting period for eligibility begins

definitions of small employer

defined as one that employed between 2-50 employees the preceding calendar year

dependent child age limit

for purposes of defining the limiting age in an accident and health insurance policy issued in NY, the policy must generally include as a dependent child any child who is 19 years old or younger

Medical examination and lab tests including HIV

for underwriting an individual policy, insurers may require proposed insureds to undergo an HIV test, but only in conjunction with other medical tests the basis for requiring an HIV test cannot be proposed insured's sexual orientation the insurer must obtain written consent from the proposed insured in order to conduct the HIV test

how long should insurer maintain advertising files

four years from the date the ad was last used

small group health plans must be

guaranteed renewable

Group health certificate

in New York, a it must contain a summary of policy features and benefits

time payment of claims

indemnity claims will be paid immediately upon receipt of written proof of loss. If benefits are to be paid over a period of time, they cannot be paid any less often than monthly

infertility

individual and group health insurance policies may not exclude coverage of a condition solely because the medical condition results in infertility plans must cover the diagnosis and treatment of infertility for insureds between the ages of 21 and 44 who have been covered under a policy for at least 12 months

there must be prior state approval for Medicare Supplement informed used in:

insurance company brochures and radio/television advertisements made by the insurer

to verify if replacement is involved in a Medicare Supplement sale,

insurance law requires that a question about replacement appear on the application form

advertisements must clearly identify the

insurer and the policies or services advertised. any use of statistics in an ad must include the source of the statistics

nonforfeiture benefits (long term care)

insurers must give long-term care applicants the option of including a nonforfeiture benefit that provides protection if a policyowner cancels a policy or lets it lapse benefits are based on the amount of time the policyowner has had the coverage and the total amount of premiums paid

ads cannot state that a policy is an

introductory, initial, or special offer and that applicant will therefore receive special advantages not available at a later date or that the offer is available only to a certain group of individuals, unless that is true

when a small employer health insurance plan is offered , it

must be available to all eligible for coverage

outline of coverage (long term care)

must be delivered to a prospective applicant for long term care insurance by the producer at the time of initial solicitation an outline of coverage must describe a long term care policy's benefits, exclusions, renewal provisions, and continuation provisions

Notice to buyer (long term care policy)

must be on the first page of each long term care policy delivered in it explains that some long term care cost may not be covered

pre-existing conditions/group coverage

pre existing condition are health issues that existed, were treated, or diagnosed within 6 months prior to employment an enrollee for a health benefit plan may be excluded for up to 12 months (18 months for late enrollees) a late enrollee is an individual who elects coverage after the initial eligibility period

insurers can use government publications for communicating Medicare Supplement information without

prior state approval

Long term care policy is any policy designed to

provide coverage for at least 12 consecutive months for each covered person on an expense-incurred, indemnity, prepaid, or other basis eligibility for benefits may require the inability to perform up to 3 activities of daily living (ADL's)

marketing materials cannot state or imply

that an insurer or policy has been approved or endorsed by a governmental entity unless it is true the nature and extent of such a recommendation, endorsement, or rating must be fully explained

an ad that intended to be seen or heard beyond the jurisdiction in which the insurer is licensed cannot imply that

that insurer is licensed beyond that jurisdiction

under Long Term Care policy, if a direct insurer is selling the policy,

the Notice to Applicant Regarding Replacement of Accident and Health insurance must be delivered with the policy, and the insured is entitled to a 30-day-free-look-period

under Long Term Care, if the sale involves replacement, the insurer or producer is required to provide

the applicant with a Notice to Applicant Regarding Replacement of Accident and Health insurance this notice must be given when the producer takes the application

newborn child coverage - if a premium is required to continue the newborn's coverage, it must be paid within

the first 30 days to continue coverage coverage includes injury and sickness, including medical care for diagnosed congenital defects and birth abnormalities

physical exams and autopsies

the insurer has the right to examine the insured during the claim process and to make an autopsy when death is involved and where it is not forbidden by law

Intoxicants and Narcotics

the insurer shall not be liable for any loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of narcotics unless administered on the advice of physician

an ad cannot make

unfair or incomplete comparisons of policies or benefits offered by other insurers. it cannot disparage competitors or their products, services, or business methods and cannot disparage other methods of marketing insurance

change of beneficiary

unless the insured makes an irrevocable beneficiary designation, the insured retains the right to change the beneficiary by giving written notice to the insurer consent of any beneficiary is not required for the insured to surrender or assign the policy or to change any beneficiary, or for other changes in the policy

if a health policy is reinstated after it had lapsed for nonpayment, there is a

waiting period of 10 days before a claim covering sickness will be covered injuries sustained from an accident, however, will be covered immediately

probationary period in a group dental insurance

to help hold down coverage for preexisting conditions

application for Medicare supplement insurance must include a statement signed by the agent as

"I have reviewed the current health insurance coverage of the applicant and find that additional coverage of the type and amount applied for is appropriate for the applicant's needs"

in the Health Insurance Marketplace, cost share reduction are sometimes called

"extra savings"

as defined by the Affordable Care Act, the MAXIMUM amount an individual can contribute to a Flexible savings Accounts is

$2,500

prohibited long-term care and Medicare supplement sales practices

1 twisting 2. high pressure tactics 3. cold lead advertising 4. misrepresentation

(Patient Protection and Affordable Care Act) beginning January 1, 2014, the exchange shall allow any qualified plans, as well as benchmark plans, that meet the minimum standards established by the exchange to be offered in the exchange all plans must include the following:

1. ambulatory patient services 2. emergency services 3. hospitalization 4. maternity and newborn care 5. mental health and substance use disorder services, including behavioral health treatment 6. prescription drugs 7. rehabilitative services and devices 8. laboratory services 9. preventative and wellness services and chronic disease management 10 pediatric services, including oral and vision care

what are the reason business should provide their employees with leave up to 12 weeks

1. birth of a newborn child of the employee 2. placement of a child with an employee for adoption or foster care 3. care of an employee's parent, spouse, or child with a serious health condition 4. serious health condition of the employee that renders him or her unable to work 5. sudden qualifying necessity arising from a family member being on active military duty, or being called to active duty, in the National Guard or Reserves

under the Affordable Care Act (ACA), the health insurance exchange will perform all of the following roles:

1. certify health plans as qualified, based on predetermined criteria 2. utilize individual, unique formats for presenting health benefit plan options 3. verify and resolve inconsistent information provided to the exchange by applicants

ERISA mainly sets requirements and standards in three areas:

1. information disclosure 2. accountability 3. claims procedures and appeals

with regard to group health insurance, ADEA impacts participants in two key ways:

1. older worker cannot be denied coverage under a group health plan 2. an employer can either provide equal benefits to all workers regardless or age or reduce the benefits provided to older workers as long as they pay essentially the same premium for older employees as younger ones, employers may offer Medicare-eligible employees a separate form of coverage hat effectively makes Medicare the primary provider. This is the legal bases of the Medicare carve-out plan

besides illness, treatment or medical conditions arising from war or act of war, what else could be included in the limits and exclusion?

1. participation in a felony, riot, or insurrection 2. service in the armed forces or auxiliaries 3. suicide, attempted suicide, or intentionally self inflicted injury 4. aviation as a crewmember or non-fare paying passenger

(New York Disability benefits Law) under workers compensation, the following would be expected to cause permanent disability

1. permanent loss of use an upper extremity (shoulder, arm, hand, wrist, finger) 2. permanent loss of use of lower extremity (hip, leg, knee, ankle, foot toe) 3. loss of eyesight of hearing

Exclusion or limitation of benefits on the basis of Alzheimer's Disease or dementia is NOT permitted. However, limits and exclusion may be placed on:

1. pre-existing conditions or diseases 2. mental or nervous disorders 3. alcoholism and drug addiction 4. illness, treatment or medical conditions arising from war or act of war 5. treatment in a federal government facility 6. service for which Medicare pays benefits 7. services for which state or federal workers' compensation pays benefits 8. services for which employer's liability, occupation disease, or a motor vehicle no-fault law provides benefits 9. services provided by a member of the insured's immediately family 10. services for which no charge is usually made in the absence of insurance 11. coverage while the insured is outside the US and its possessions

(Patient Protection and Affordable Care Act) "Exchanges" are created by the Affordable Care Act (ACA) health reform bill help individuals and small business purchase health insurance coverage. the purposed of the exchange include:

1. reduce the number of uninsured in the state 2. facilitate the purchase and sale of qualified health plans in the individual market 3. assist qualified employers in the state in enrolling their employees in qualified health plans 4. assists individuals in accessing public programs, premium tax credits, cost-sharing reductions

dependent children of married parents - the order of benefits for dependent children is as follows when they are covered by two or more health insurance plans:

1. the benefits of the plan of the parent whose birthday (month and day) is earlier in the year pays benefits before those of the plan of the parent whose birthdays is later in the year 2. if both parents have the same birthday, the plan that has covered the parent longer pays benefits before the plan that covers the other parent pays benefits

coverage will end upon the earliest of:

1. the individual's failure to pay premiums 2. 36 months after the date the individual's group coverage would have ended due to termination of employment 3. the date the group policy is terminated

Relation of Earnings to Insurance - if the total monthly benefits paid under a disability income policy exceed one of the following--which is greater-then the insurer can reduce the benefits proportionally:

1. the monthly earnings of the insured at the time the disability began 2. the average monthly earnings of the insured during the two years before the disability this will prevent overinsurance of the insured, who might otherwise profit from the disability. Premiums paid for excess coverage will be returned to the insured

dependent children of separated or divorced parents - the order of benefits for dependent children is as follows when they are covered by two or more health insurance plans:

1. the plan of the parent with custody of the child pays benefits first 2. the plan of the spouse of the parent with custody of the child pays next 3. the plan of the parent who does not have custody of the child pays last however, if a court orders one of the parents to be responsible for the health-care expenses of a child, that parent's plan will be the primary coverage the other parent's plan will be the secondary coverage

Order of benefit payment - the order in which benefits are paid under a Coordination of Benefits provision are generally as follows:

1. the primary plan pays its benefits as if the secondary plan did not exist. Hoever, if coverage is intended to supplement other insurance that supplementary coverage will be excess to any other coverage 2. a secondary plan can take benefits paid under another plan into consideration only when it is secondary to that other plan 3. a plan that covers the insured as an employee or subscriber (but not as a dependent) pays benefits before those of a plan that covers the insured as a dependent

a MEdicare Supplement policy must disclose:

1. the right to return policy for a full refund 2. any limitation on pre-existing conditions 3. the right of the insurer to increase premiums

eligible employees who are family members of a person serving in the

National Guard or Reserves are entitled to the 12-week leave period

Child Health Plus

New York offers a health insurance plan for kids children are eligible for this insurance if they are under age 19, are residents of New York, are not eligible for Medicaid, and do not have other health insurance

free look (long term care)

a 30 day free look period is required for long term policies

prosthodontics

a branch of dentistry dealing with the replacement of missing parts using biocompatible substitutes such as bridgework or dentures

periodontics

a dental specialty that involves the prevention, diagnosis and treatment of disease of the supporting and surrounding tissues of the teeth or their substitutes it also involves the maintenance of the health, function, and esthetics of these structures or tissues

cost share reduction

a discount that lowers the amount a purchaser has to pay for deductible, copayments, and coinsurance

Cost Share Reduction (CSR)

a discount that lowers the amount a purchaser has to pay for deductibles, copayments, and coinsurance

APTC (Advanced Premium Tax Credit

a federal tax credit for individuals that lessens the amount they pay for health insurance premiums for health insurance on the Marketplace

APT (Advance Premium Tax Credit)

a federal tax credit for individuals that lessens the amount they pay for health insurance premiums for health insurance on the marketplace

accountability (ERISA)

a fiduciary must be named. the fiduciary administers the health plan in a financially responsible manner and in the best interests of its enrollees

Grandfathered Plans do not have to follow the ACA's rules and regulations or offer the same benefits, rights and protections as new plans what is the exception?

a grandfathered plan cannot impose lifetime limits on how much health care coverage people may receive

Conversion Privilege

a group health plan must provide that an employee or member who has been insured continuously for at least 3 months and whose coverage is terminated (due to loss of employment or termination of the group policy) is entitled to convert his or her coverage under the group plan to individual coverage under a separate health insurance policy an individual policy will be issued to that person even without evidence of insurability

employer groups

a group policy may be issued to an employer to an insure its employees if: 1. all eligible members are insured if the union pays the entire premium 2. at least 50 percent of the members are insured if the members pay part of the premium 3. at least 50 persons are insured on the date of issue (100 persons if the members pay part of the premium)

dental treatment expense required to repair an injury would normally be covered under

a hospital or medical expense policy

advertisement may not describe

a limitation or exception in a positive manner to imply that is a benefit, such as by describing waiting periods as "benefit builders" or stating that "even pre-existing conditions are covered after two years"

entire contract

a provision that the policy (including the endorsements and the attached papers) along with the written application shall constitute the entire contract between the parties

define community rates

a rating methodology in which the premium for all insureds is the same based on the experience of the entire pool of risks covered by the policy, without regard to age, sex, health status, or occupation

small employers may require employees to work

a specified number of hours to qualify as an employee (not more than 20 hours)

beginning January 1, 2014, the Patient Protection and Affordable Care Act (ACA) will require

adjusted community rating in the small group market. small group health plans will be allowed to vary rates only based on whether the policy covers an individual or family, geographic area, age, and tobacco use

Contestability Period (Time Limit on Certain Defenses)

after a health insurance policy has been in effect for two years, the insurer can void the policy r deny a claim only on the basis of a fraudulent misstatement the insured made in the application

who are subject to FMLA?

all business with 59 or more emoloyees they are required to provide eligible employees with up to 12 weeks of unpaid leave each year

coverage of adopted children

all individual and group health plans must provide coverage to the insured's adopted children on the same basis as other dependents

newborn child coverage

all individual and group health plans which provide coverage to family members of the insured must provide coverage for the insured's newborn child at the moment of birth

inflation protection

all insurers issuing long-term care insurance polcies must offer, as an optional benefit, an inflation protection feature which provides for automatic future increases in the level of benefits without evidence of insurability

the Pregnancy Discrimination Act of 1978

amended the Civil Right act to make discrimination on the basis of pregnancy, childbirth, or related medical conditions unlawful as a form of sexual discrimination

continuation of coverage under COBRA - when terminating an employee, the employer is required to notify the employee of this right to continue coverage

an employee must apply to continue coverage within 60 days of leaving the group plan or receiving a notice of the right to continue coverage if the employee or member decides to continue coverage under the group plan, he or she must pay the entire group premium, including the portion usually paid by the former employer

small employer insurance plan - once accepted for coverage

an individual or small group's coverage must be renewed and cannot be terminated by the insurer due to claims experience

claim forms

an insurance company will send forms for filing proof of loss to a claimant within 15 days after company receives notice of a claim

reinstatement for military personnel

any employee who leaves employment to perform service with the military and reapplies for coverage after release shall be reinstated, regardless of preexisting condition

Conformity with State Statutes

any provision of this policy which, on the date of issue, is in conflict with the statutes of the state in which the insured resides at the date of issue is understood to be amended to conform to such statutes

pre-existing condition (long term care)

are those which medical advice or treatment was recommended by or received from a health provider within 6 months preceding the effective date of an individual long term care policy

New York State partnership for Long Term Care - partnership policies contain an

asset protection feature. after a policyowner has used up all of his or her partnership policy benefits, the person can apply for Medicaid but is not required to first spend down his or her assets to the poverty level the person can keep a certain amount of asses, depending on the type of partnership policy purchased, and Medicaid cannot recover such assets at the policyowner's death

(ACA requirements) low income individuals and families whose incomes are

between 100% and 400% of the federal poverty level will receive federal subsidies on a sliding scale if they purchase insurance via an exchange

lower premium plans will have higher deductibles, less benefits and larger out of pocket costs the actuarial level is calculated as the percentage of total average cost for covered benefits that a plan will cover

bronze plans: 60% actuarial level of coverage provided silver plans: 70% actuarial level of coverage provided gold plans: 80% actuarial level of coverage provided platinum plans: 90% actuarial level of coverage provided

prepaid dental plans

coverage is limited to a closed panel of dentists

Healthy New York

designed to help small business provide health insurance to their employees and employees' families uninsured sole proprietors and workers whose employers do not offer health insurance may also purchase coverage through the Health New York program each of these groups has its own eligibility criteria and participation requirements

Long term care insurance

designed to provide coverage for diagnostic preventive, therapeutic, rehabilitative, maintenance, or personal care services in a setting other than an acute care unit of a hospital a health insurance agent license is required in order to solicit this type of insurance

testimonials, appraisals, analyses, or endorsements made by persons having a financial interest in the insurer must

disclose this fact in the marketing materials paid endorsement must also be disclosed with a clear and prominent notice, such "Paid endorsement"

genetic testing

discrimination based on genetic information is prohibited

ADEA (Age Discrimination in Employment Act) prohibits

employers from discriminating against those who are at least 40 years old

how long of a leave could a employee who are family members of persons in military service have

entitled to 26 weeks of leave within a 12-month period to care for a service member who has a serious illness or injury incurred while on active military duty these 26 weeks are an extension of the 12 weeks normally provided under the act

advertising file

every insurer must keep in its home office a file that contains every advertisement used to market its health insurance policies, with information concerning how and to what extent the ad was distributed this file is subject to examination by the Department

any individual may satisfy part of the eligibility requirements for the New York Health Plan ( AKA New York Health Insurance Association) by providing

evidence of an insurer's refusal to provide comparable insurance for health reasons

endodontics is commonly

excluded or limited from a dental policy

cold lead advertising

failing to disclose that the purpose of the marketing efforts is insurance solicitation

to qualify for federal tax deductions, group insurance plans must comply with

federal laws such as the Pregnancy Discrimination Act in practical terms this means group medical insurance plans must cover pregnancy as they would any other medical condition

example of restorative dentistry

filings, crowns, and dental bridges

testimonials, appraisals, analyses, or endorsements used in marketing materials must be

genuine and represent the current opinion of their author these must be reproduced accurately and completely enough to avoid misleading prospective customers about their nature or scope

Family and Medical Leave Act (FMLA)

gives certain employees up to 12 weeks of unpaid leave per year while protecting their employed status employees can take leave for family and medical reasons group health benefits must be maintained for the employee through the FMLA period

(Medicare Supplement) the insurers must provide an offer of conversion to individual coverage to certificate holders when a

group Medicare Supplement insurance policy is terminated and not replaced

information disclosure (ERISA)

group health plan enrollees must be given written information about the plan in the form of a summary plan description

dependent child coverage

group health plans which cover the insured's dependents must allow children and dependent grandchildren to continue coverage under a parent's health plan until age 26 handicapped children are not subject to an age limitation and are covered until they become self-supportive * the insurer is entitled to proof that the child is incapacitated and dependent upon the insured parent within 31 days of the child reaching the limiting age

(Patient Protection and Affordable Care Act) preexisting conditions

health plans cannot limit or deny benefits or deny coverage for a child younger than age 19 because of preexisting conditions this applies to both group and individual policies

there is a "Platinum plan" which is the

highest quality and cost plan

continuation of coverage under COBRA

if a person is no longer a member of an insured group (due to loss of employment or termination of group membership) he or she is permitted to continue his or her coverage under the group plan

policy extension for handicapped children

if an employer has purchased a group health insurance policy which covers dependents, New York Insurance Law mandates continuation of coverage for unmarried disabled dependent children who are not capable of self-sustaining employment, as long as the insurance remains in force and the dependent remains in such condition

Policy Extension for Handicapped Children

if an employer has purchased a group health insurance which covers dependents, New York insurance Law mandates continuation of coverage for unmarried disabled dependent children who are not capable of self-sustaining employment, as long as the insurance remains in force and the dependent remains in such condition

comprehensive dental plans usually provide

routine dental care services without deductibles or coinsurance to encourage preventative care (such as teeth cleaning, fluoride treatment etc)

reinstatement

if an insurer fails to approve a reinstatement application within 45 days, the policy will be automatically reinstated unless the insurer has given written notice to the insured that it will not reinstate policy

Timothy's law

in New York, group health insurance plans must provide certain benefits for mental health services employees are entitled to at least 30 days of inpatient care and at least 20 outpatient care visits for mental, nervous, or emotional disorders each year

contract changes

in a health insurance contract, changes may be made only when approved in writing by an officer of the insuring company

indemnity basis

in long term care policies that use an indemnity basis , the policy pays a specified amount to the policyholder, up to a daily or monthly maximum regardless of the actual cost of care

a producer's commission for the dale of a Medicare supplement policy

in the first year following its effective date cannot exceed 200 percent of the commission paid for selling or servicing the policy in the second year

Health New York

is designed to help small business provide affordable health insurance to their employees and employees' families

Genetic screening information

it is ilegal for insurers to use the results of a proposed insured's genetic screening to: 1. underwrite a policy 2. determine whether to issue an insurance policy or to cancel 3. refuse to issue or renew, or limit benefits of a policy

misrepresentation

misrepresenting a material fact in selling a long-term care insurance policy

(New York Disability benefits Law) exclusions

new york workers compensation laws exclude benefits for disabilities caused by intentional, self-inflicted injuries on the job

dental insurance

part of a health benefits package with a single deductible called an integrated deductible, applying to both medical and dental coverages

a pre-treatment estimate of the cost of dental services may be required whenever

patient requires dental treatment

(Patient Protection and Affordable Care Act) Grandfathered plans

plans that ere purchased before March 23, 2010. These plans do not have to follow the ACA's rules and regulations or offer the same benefits, rights and protections as new plans

dental plans are typically indemnity plans which pay benefits based on a

predetermined, fixed rate set for the services provided...regardless of the actual expense incurred

the absence deductible on routine examination encourages

preventive care in dental insurance

inflation protection - adjustments must be at a level which

provides reasonable protection from future increases in the costs of care for which benefits are provided * increases benefit levels annually in a manner so that the increases are compounded annually at the rate of at least 5% * no evidence of insurability required

any individual may satisfy part of the eligibility requirements for New York Health Plan by

providing evidence of an insurer's refusal to provide comparable insurance for health reasons

uninsured sole proprietors and workers whose employers do not offer health insurance may also

purchase coverage through the Healthy New York program each of these has its own eligibility criteria and participation requirements

in addition to covering qualifies retirement plans, ERISA

regulates and protect those enrolled in group health plans

Medicare Supplement policy must be guaranteed

renewable and cannot be cancelled due to individual's health status

the New York State partnership for Long Term Care Program offers a way for

residents to buy long-term care insurance, receive benefits, and protect a matching amount of assets if they ever need to apply for long-term care assistance through Medicaid

(Medicare Supplements) the producer who solicits the application is primarily

responsible for determining the appropriateness of a Medicare supplement policy for a proposed insured

what is an example of Endodontics

root canals

some dental policies are

schedules, meaning benefits are limited to specified maximums per procedure, with first dollar coverage most, however, are comprehensive policies that work in much the same way as comprehensive medical expense coverage in addition to deductibles, coinsurance and maximums may also affect level of benefits payable under a dental plan

dental coverage and claims are handled separately with a

separate deductible

some hospital and medical expense plans will provide coverage for some dental related services related to the jaw or facial bones

some of these includes: 1. reduction of any facial bone fractures 2. removal of tumors 3. treatment of dislocations, facial and oral wounds/ laceration in order to repair an injury 4. the removal of cysts or tumors of the jaws or facial bones

ERISA

stands for the federal Employment Retirement Income Security Act of 1974

Oral and Maxillofacial Surgery

surgery that treat many diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region

what does the Pregnancy Discrimination Act state?

that "women affected by pregnancy, childbirth, or related medical conditions shall be treated the same for all employment-related purposes including receipts of benefits under fringe benefit programs, as other persons not so affected but similar in their ability or inability to work

(Patient Protection and Affordable Care Act) Lifetime and annual limits

the ACA prohibits health plans from putting lifetime dollar limits on most benefits are receive by an insured - for plans starting on or after September 23,2012, but not before January 1, 2014, the annual dollar limit is $2 million. After January 1, 2014, there are no annual dollar limits - plans are allowed to put an annual dollar limit on health care services that are not considered essential

benchmark plan

the affordable care act (ACA) requires that all non-grandfathered health plans sold in the individual and small group markets cover certain essential health benefits, which are required by the ACA

According to the Affordable Care Act, if a large employer does NOT provide health insurance and owes an employer mandate penalty

the annual penalty is calculated by multiplying $2,000 by the number of full time employees minus 30

according to the Affordable Care act, if a large employer does NOT provide health insurance and owes an employer mandate policy penalty

the annual penalty is calculated by multiplying $2,000 by the number of full time employer minus 30

endodontics

the branch of dentistry dealing with diseases of the dental pulp

if a benefit okan is offered on an Exchange

the insurance company must offer the same plan outside of the Exchange

insurance companies are not permitted to rescind coverage UNLESS

the insured intentionally puts fake incomplete information on the application

illegal occupation

the insurer shall not be liable for any loss to which contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation

if an insurer fails to adhere to the Affordable Care act requirements related to internal appeals

the internal appeal may be deemed exhausted for purposes of submitting an external review

to prvenet adverse selction in a group dental expense plan

the plan may require any of the following: 1. probationary periods, 2. waiting periods, 3. evidence of insurability, or 4. limits on annual benefits

When a Medicare supplement policy is purchased during the open enrollment period

the policy must be issued regardless of health status

Restorative dentistry

the procedure for restoring the function and integrity of a missing tooth structure

when a Medicare Supplement insurance policy is being replaced,

the producer and applicant must sign the notice of replacement, notify the replaced insurance company, and give a list of all health policies the producer sold to applicant in the past

orthodontics

the treatment of irregularities in the teeth (esp. of alignment and occlusion) and jaws, including the use of braces

under the Affordable Care Act (ACA), parents can insure their dependent adult children up to

their 26th birthday, even if they are married or not living with their parents

(Patient Protection and Affordable Care Act) metal levels

there are four tiers of "qualifying health plans" you or your employer can purchase on the exchange they range from lower quality, but more affordable "Bronze plans", to "Silver plans" to a more expensive plan with better coverage called a "Gold plan". There is also a "Platinum plan"

legal action

there is a waiting period of 60 days to file a lawsuit after a claim for loss has been filed by the insured no lawsuit may be filed after 1 year has passed from when the claim was submitted

Child Health Plus

this is the name of what New York offers a health insurance plan for kids Children are eligible for this Plan if they are under age 19, are residents of New York, are not eligible for Medicaid, and do not have other health insurance

administrative capability

to be eligible to participate in group healthcare plans, an employer must demonstrate that it is administrative capable of providing the contribution it promises and can properly manage the healthcare programs

Health Insurance Portability and Accountability Act (HIPAA)

under Health Insurance Portability and Accountability Act (HIPAA), some insurers are required to guarantee issue policies to HIPAA eligible individuals, regardless of their health status these individuals include people who have had at least 18 months of prior coverage under a group plan and without more than a 63 days gap in coverage states can decide whether that coverage should be available from private insurers or available from the state's high-risk pools while this requires that coverage be made available, it doesn't limit how much insurers can charge HIPAA-eligible individuals for coverage and this coverage can be very expensive

Reimbursement basis

under a long term care policy that is issued on a reimbursement basis, the policyholder is reimbursed for the actual expenses he or she incurs for covered services, typically up to a daily or monthly cap

New York Disability benefits Law

under this Law, cash payments are provided to workers who are unable to work because of injury or illness that occurred on the job

high pressure tactics

used to induce the purchase of insurance through force, fright, threat, or undue pressure

twisting

using misrepresentations or inaccurate comparisons to induce a person to terminate or borrow against their current insurance policy to take out an insurance policy with another insurer

New York Health Insurance Association

was created t insure high risk citizens of this state who, because of pre-existing health conditions, cannot obtain coverage

New York Health Insurance Association (LHIA)

was created to insure high risk citizens of this state who, because of preexisting health conditions, cannot obtain coverage

the age Discrimination in employment Act (ADEA)

was passed in 1967 and later amended in 1986 and 1991

pre-existing condition, replacement policies (1)

when replacing an individual health policy in New York, the required replacement notice to the applicant must include notice that pre-existing conditions may not be covered

replacement

when replacing individual heath insurance, a producer should compare existing benefits with the proposed new policy to determine if existing benefits would be maintained under the new plan

replacement (long term care)

when soliciting or selling Long Term Care insurance policies, insurers and producers are required to follow the usual rules concerning replacement

Notice of claim

written notice of claim for injury r for sickness must be given to the insurer within 20 days after the date of occurrence

proof of loss

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

claims procedures and appeals (ERISA)

written rules are required for how claims must be filed and how participants can appeal if they are denied covered services claims appeals processes must be fair and timely