Colorado Health Insurance Law

A newborn child is covered from birth for ____ days.

31

If required, notification of birth and premiums must be paid within ____ days.

31

Health plans issued to a person NOT receiving a federal subsidy to help pay for coverage must contain a ____ day grace period.

31 day

A producer must remit premiums to insurer within ____ days after receipt.

45

Education documents must be retained for ____ years

5

Every 24 months the producer must complete at least ____ hours of LTC CE.

5

Insurers must offer inflation protection that increases benefit levels at an annual rate not less than ____ %.

5

Commissioner must examine every licensed insurer at least once every

5 years

Prelicensing Education Requirements

50 hours life insurance 50 hours accidental and health insurance 100 hours life, accident, and health insurance 50 hours property and casualty Minimum 3 hours ethics per 50 hour course

If a long-term care policy has been in force for less than ____ months, an insurer may rescind the policy or deny a claim due to material misrepresentation.

6

Open enrollment period is the ____ month period after an individual is both ag 65 or older and is first enrolled in Medicare Part B.

6

Maximum preexisting condition exclusion period

6 months

First-party property and casualty claims must be paid by insurers within ____ days of receipt unless disputed, unfair claims practices.

60

If the policy lapses due to nonpayment of premium by a policyholder with a cognitive impairment, the carrier must provide a ____ day reinstatement period.

90

Waiting period may not exceed ____ days.

90

Controlled Business

Insurance written in licensee's own interests or interests of spouse or employer, if total during 12 month period premiums on controlled business exceed the total premiums on all other business, Commissioner will not grant or renew any license used for controlled business

Guaranteed Renewability

Insurer may only discontinue health coverage if - nonpayment of premium - fraud or intentional misrepresentation - carrier discontinuing coverage in state (policyholders need 180 days notice)

Prompt Pay for Claims

Policyholder, insured, or provider may submit a claim by - US mail, first place, or overnight - email - fax - hand delivery - uncontested claims will be paid, denied, or settled within 30 days after receipt by carrier if submitted electronically (45 days by other means)

Rebating

Practice of giving something of value to a prospective insurance applicant in exchange for purchase of policy, considered unfair method of competition

Group Mental Health Coverage

Preauthorization or utilization review mechanism used to determine coverage must be same as, or no more restrictive than, that used in determination to provide coverage for physical illness - biologically based mental illness - schizophrenia, bipolar, major depressive disorder, specific OCD - mental disorder - PTSD, drug/alcohol disorders, dysthymia, cyclothymia, social phobia, agoraphobia, anorexia/bulimia, anxiety

Small Group Participation Requirements

Requirements insurer uses to determine whether to provide coverage to small employer must be applied uniformly among all small employers applying/receiving coverage from that carrier

Unfair Trade Practices

Without a hearing if an unauthorized person is engaged in insurance business without license or in violation of a rule and appears to be fraudulent, creates immediate danger, or is about to cause significant public injury

If the policy has bee in force for at least 6 months, but less than ____ years, an insurer may rescind the policy or deny a claim if it can show that is issued the policy upon a material misrepresentation that relates to the claim.

2

If the policy has been in force for at least ____ years, an insurer may contest a policy only if the insured knowingly and intentionally misrepresented relevant facts concerning his health.

2

Producer's license continually renewed as long as proper fees and continuing education requirements are met for how long?

2 years

Division of Insurance records and requests inquiries must be answered within ____ calendar days.

20

Total continuing education (CE) hours required for each two year licensing period

24 hours -3 hours ethics -18 hours in lines which licensed -3 hours homeowners for property and personal

Health plans issued to a person receiving a federal subsidy to help pay for coverage must contain a ____ month grace period.

3 month

Violators of long-term care insurance laws are subject to a fine of ____ times the amount of commissions paid, or up to $____, whichever is greater.

3 times $10,000

A producer must return all premium to the insured within ____ days.

30

The Commissioner must be notified from insurer within ____ days after date of producer appointment termination

30

The producer must file a response with the Commissioner within ____ days of receiving notice

30

To be considered an eligible employee, the minimum number of hours worked must be more than ____ hours.

30

Any administrative actions or criminal prosecutions must be reported to Commissioner within

30 days

Change of address (resident producers) must be reported in writing within

30 days

Insurance Producer

Person who solicits, negotiates, effects, procures, delivers, renews, continues, or binds insurance policies for risks in CO, membership in certain health care prepayment plans, or membership in certain health care plans

Non-resident producers moving from one state to another must file change in address and provide certification from new resident state within

30 days

Commissioner's Duties

-Maintaining records that insurers are required by law to file in Commissioner's office, annual report by March 1 -Requiring domestic insurers to keep adequate records and complies with the law -Certificate of authority- insurer's license to transact insurance business, expires on June 30 and renewed annually -Investigating violations of insurance laws and presenting findings -Transmitting funds collected by Division of Insurance to state Department of Treasury -Adopting rules and regulations -Determining whether rates are excessive, inadequate, or unfairly discriminatory

Individual Enrollment Periods

-Open enrollment - plans eff on/after January 1st are open November 1st through December 15 of previous year -Triggering event - special period of 60 days, can enroll in new plan 30 days prior to date of triggering event if known ahead of time

Producer license is not required of fraternal benefit society representative if did not receive sales compensation and

-Preceding calendar year, representative sold society life insurance contracts with face value of $50,000 or less -Sold any other kind of insurance on behalf of society to 25 or fewer individuals and received no compensation

Individual Plan Grace Period

-plan that received federal Advance Payment Tax Credits has 3 month grace period when policyholder previously paid at least 1 full months premium during current benefit year -30 day advance notice of cancellation from provider

Number of eligible full-time employees for small group health plan.

1 to 100

Sales and Marketing of Health Insurance

1. Small employer carriers must provide price quote within 5 business days after receiving all information needed 2. Small employer carriers cannot establish producer commission or bonus programs that discourage marketing to very small groups 3. Small employer carriers must actively market all their health benefit plans to small employers in all areas where carrier is authorized to conduct business in CO 4. Producers and carriers may not advise/discourage a small employer to provide coverage for an employee or dependent through another policy in order to separate person from group policy 5. Producers and carriers must maintain toll-free service to provide info to small employers about availability of small employer health benefit plans in CO

Requests for information during a market conduct or financial examination must be responded to within ____ days.

10

Up to a ____ month extension may be granted by Commissioner

12

Maximum number of hours that may be carried over to next CE period

12 hours

Maternity coverage must be provided on employer group health policies, unless the employer has fewer than ____ full-time employees.

15

An insurer has an additional ____ days to notify the producer

15 (45 total)

Producer must complete a one-time ____ hour LTC training course.

16

Minimum age for license

18

Preventative Heath Care Services

All individual and group accident and health policies in CO must cover total cost of - breast cancer mammography screening - prostate screening - cervical cancer screening - cholesterol screening

Essential Health Benefits

Ambulatory patient services, emergency services, hospitalization, lab services, maternity/newborn care, mental/behavioral health and substance abuse services, pediatric services (oral and vision included), prescriptions, preventative/wellness services, chronic disease management, rehabilitative and habilitative service and devices

Colorado Long-Term Care Partnership policies permit individuals to protect assets from the state's Medicaid program. The asset eligibility and recover provisions of the CO Medicaid program disregard assets equal to _________.

Amount of benefits received from the policy

Small Employer

Any person, firm, corporation, partnership, or association actively engaged in business employed an average of at least 1 but no more than 100 eligible employees on business days during immediately preceding calendar year, and not formed primarily for purpose of purchasing insurance

Insurance Commissioner

Appointed by and serves at the will of the governor, hires employees to help carry out duties, deputy commissioner steps in when commissioner is out

Coverage for hospital stay following vaginal delivery of a baby

Cannot be limited to less than 48 hours, if 48 hour period ends after 8pm coverage continues until 8am following morning

Coverage for hospital stay following cesarean section delivery of a baby

Cannot be limited to less than 96 hours, if 96 hour period ends after 8pm coverage continues until 8am following morning

Small Group Rating Factors

Carrier cannot require person to pay premium that is greater than the premium or contribution for similarly situated individual enrolled in plan based on any health status related factor - may impose premium surcharge of up to 35% above modified community rate if insurance has been discontinued because of nonpayment or fraud (up to 12 months)

Individual Plan Termination

Carrier must give policyholder 30 days advance notice, cannot retroactively terminate policy except for fraud or intentional misrepresentation

Group Coverage Leasing Companies

Carrier offering health coverage from employee leasing companies must ensure that a plan that covers more than 50 employees complies with provision of Colorado law that applies to large employer health plans

Small Employer Carrier

Carrier that offers health benefit plans covering eligible employees of one or more small employers

Penalty for any person applying for/holding and insurance producer license found to have violated insurance laws or rules of state or any other state

Civil penalty of up to $3,000 per violation

Investigation of Application for Insurance Producer License

Commissioner can examine/investigate person who is applying for license to determine if person has violated insurance laws or rules of the state or any other state

Investigating Possible Violations

Commissioner is allowed free access to books and documents relating to insurer's business and may subpoena witnesses and administer oaths during an investigation

Commissioner Examinations

Conduct formal financial examination of every insurer license in CO at least every 5 years, examinations outside of the state will be paid by insurance company, refusal to comply license could be suspended, revoked, denied, or non-renewed

Rate Regulation Laws

Created to protect public by ensuring insurance rates are not excessive, inadequate, or unfairly discriminatory -Prohibit price fixing agreements (anti-competitive behavior) -Provide rates that are responsive to competitive market conditions -Improve availability and reliability of insurance

Group Coverage Continuation Privileges

Employee may elect to continue coverage for themselves and dependents, employer must give written notice of right to continued coverage after termination within 10 days -employer must pay full monthly amount of coverage (both employee and employer's contribution) -employer not required to offer continuation if person is covered by Medicare or Medicaid

Diabetes Coverage

Equipment, supplies, self-management training, education

A license is deemed to be used for controlled business if, during any 12 month period, the total premiums on controlled business ____ the total premiums on all other business.

Exceed

Medicare Supplement

Fills gaps of original Medicare, must be guaranteed renewable -cannot cancel/refuse to renew policy solely based on health status or age -cannot exclude or limit benefits for losses incurred more than 6 months after effective date of coverage due to preexisting condition -free look period is 30 days

Small Group Eligible Employee

Full-time employee of 30+ working hours in employee-employer relationship with employer that has not been established for purpose of obtaining small group plan

Complications of Pregnancy

If policy covers disability due to accident or sickness, this extends to pregnancy if it's a complication of pregnancy or childbirth. Any disease, disorder, or condition that: - is adversely affected by or caused by pregnancy - requires physician-prescribed supervision - results in loss or expense that would normally be covered by the policy

Fraudulent Claims and Arson Information Reporting Act

Insurer must maintain antifraud plan that outlines specific procedures to prevent, detect, investigate fraud, educate employees about fraud detection and company's plan, hire one or more fraud investigators, and report suspected or actual insurance fraud

Certificate of authority expires on

June 30 each year, renew annually

Defamation

Making oral or written statements that are false, maliciously critical, or derogatory to financial condition of insurer or intended to injure anyone in insurance business -Misdemeanor -Fine $500, imprisonment 12 months, or both

Violation of Cease and Desist Order

Max $500 per violation (individual) Max $10,000 per violation (insurer)

False Testimony

Max of $5,000, 3 months imprisonment, or both

Falsifying Books or Documents

Max of $5,000, between 2 and 12 months imprisonment, or both

Unfair Trade Practices and Methods of Competition- Cease and Desist Orders

Max per violation $3,000 Max per aggregate $30,000 Max per violation knowingly committed $30,000 Max per aggregate knowingly committed $750,000

Hospice & Home Health Care

Must include coverage for at least 60 home health visits per year - terminally ill - life expectancy of 6 months or less - $150 per day for combo of routine home care services - total benefit for each period not less than daily benefit multiplied by 90 days - bereavement support for 12 months following death at least $1,400