Ch 15 laws part 3
How does a HIC (health insuring corporation) operate?
like an HMO and is regarded as managed health care system - no coverage outside of service area (except emergencies), pre-paid basis but still have copays for office and hsp (it's an admin fee to discourage waste)
In Ohio, MEWA's must meet one of the following requirements:
min enrollment of 300 EE or 2 or more ER's 2. min enrollment of 300 self-employed individuals 3. min of 300 workers in any combo of EE and self-employed
In Ohio, what is the max amt of time a policy can be backdated?
no more than 6 months before the application was made
A max of 2k is set as annual deductible for a plan covering a single individual (4k for any other plan). What about premiums?
premiums are subsidized for people with up to 400% of the poverty line as well as single adults
A violation of adverse benefit rules is an unfair or deceptive act or practice. If the insurer is guilty, what penalties do they face?
suspension or revocation of insurer's cert of authority, an admin penalty max of 100k per violation and require the insurer to correct any deficiency
Who is a viator?
the owner of a policy or a certificate holder under a group policy who sells their policy
Who is a viatical settlement broker?
works on behalf of the viator (for a fee) to negotiate with viatical settlement providers - they have fiduciary duty to viator
All life policies must have a grace period of how long?
1 month after the first premium pd.
What are some of the exceptions to not being able to enter into a viatical settlement contract w/in the 1st 5 years of issue?
1. it was converted from a group and total time covered is at least 60 months 2. viator is a charitable organization 3. viator certifies that: terminally or chronically ill, viator's spouse dies, viator retires, becomes mentally or physically disabled, goes BK, sole beneficiary is a family member and dies
If an adverse benefit determination is based on the basis that a requested service is experimental, an insured can ask dr to certify what?
1. standard health care services haven't been effective and are not medically appropriate and there are no other alternatives that are more beneficial to the insured
Each viatical contract must provide the viator the unconditional right to rescind the contract for how long?
15 calendar days after the receipt of the proceeds
What is different about Ohio's right to examine provision?
It may provide that the coverage will be in force during any period prior to its return and charge a pro rate portion of the premium on a per diem basis only. (doesn't apply to any single-premium nonrenewable policy)
In Ohio, the federal gov runs the health insurance exchange. When is open enrollment?
Nov 1 - Dec 15 for the following coverage year
How is dependent child coverage handled in Ohio?
Once an unmarried child has attained the limiting age for dependent children, the insurer must offer, upon request, to cover the unmarried child until age 26 as long as child is: child of the insured, resident or FT student of Ohio, not eligible for other coverage and not eligible for coverage under Medicaid or Medicare
What are the Ohio particulars on reinstatement for health policies?
The insurer or producer may accept the premium to reinstate the policy w/out requiring an application (and it's reinstated) - any premium can be applied to arrears but not more than 60 days prior to reinstatement
FSA's, HRA's and HSA's cant be used to pay for over-the-counter drugs (except insulin). What other provisions are in ACA?
a 2k per employee tax penalty is imposed on employers with more than 50 employees who don't offer health insurance to the FT workers
What is an AHP (association health plan) and is it considered a MEWA?
a health plan sponsored by an association for their members and EE's. Yes, they are considered MEWA's in Ohio.
When a LTC benefit is being paid, what must the insurer provide on a monthly basis?
a report including the description of benefits pd, an explanation of any resulting changes to the policy values and the amt of remaining LTC benefits.
When offering a HIC, what must the potential applicant be given?
a solicitation document
The accelerated benefit rider may not impose what restrictions?
a waiting period, proof of eligibility, or restrict the use of the accelerated DB proceeds
When must the nonforfeiture benefits be available to the owner?
after premiums have been pd for 3 years (and the benefit must be a stipulated form of ins)
The replacing insurer AND existing insurer must keep copies of the Notice of Replacement for how long?
at least 5 years or until the next regular examination by the insurance dept, whichever is later
What is a MEWA (multiple employer welfare arrangements)?
group usually formed by larger employers to obtain more favorable rates for life and health ins
An individual ins agent in good standing who has been licensed w/ a life line of authority for at least 5 years may act as a settlement broker w/out obtaining a license if what circumstance occurs?
if the viatical settlement activities are incidental to their business activities
ACA - what can't it do?
impose lifetime dollar limits on essential benefits like hsp - also can't establish annual spending caps
The replacing insurer must give the policyowner a notice of what right?
the right to return the policy w/in 30 days of delivery for a full refund
Any STOLI act entered into is considered void and unenforceable. What are violations of this rule considered?
unfair and deceptive trade practices
Within 5 business days of being notified that a policy is being replaced, what must an existing insurer do?
send a letter to the policyowner indicating the right to receive info regarding the existing policy
Replacing insurers must notify any other insurers that may be affected by a proposed replacement w/in what time period?
5 business days of receiving a completed application indicating replacement
If an insurer decides to not renew a policy (excluding accident only policies) a notice of nonrenewal must be provided to the insured how far in advance?
5 days before the premium due date
How much must insurers spend on healthcare or to improve quality?
85% of large-group and 80% of small group and individual plan premiums - or return the difference to the cx as a rebate
If a group plan life ins is terminated, what rights do the members have?
everyone who has been insured for at least 5 years before the termination is entitled to a 31 day right of conversion - coverage is limited to the lesser of 10k or the group policy's amt
When could an attorney, CPA or financial planner (accredited by a nationally recognized agency) negotiate viatical settlement contracts w/out obtaining a license?
if they aren't compensated directly or indirectly by the settlement provider or purchaser
How long does special enrollment last?
in the Individual Marketplace its 60 days from the date of the event and 30 days for Small Business Health Options Program (SHOP) Marketplace
What happens if a viator dies w/in the 15 day right to rescind period?
it is deemed to be rescinded and funds are returned to the settlement provider
If an insurer receives a request for an external review of an adverse benefit determination, how long do they have to respond and how?
it must provide all documentation to an independent review organization w/in 5 days
What are the rules to be a licensed viatical settlement broker?
license renews yearly on March 31st and must have 15 hrs of CE biennially
Time limit on certain defenses includes what provision in Ohio?
no claim may be reduced or denied based on pre-existing, chronic disease or chronic physical condition except by name of specific description
In viatical advertising, if the ad emphasizes speed of transaction, it must disclose the avg time of viatication. If they emphasize the dollar amt avail to viators, what must it disclose?
the avg purchase price as a % of face value obtained by viators in the last 6 months
CHIP is avail for who?
uninsured people under 19 with family incomes between 150% and 200% of the federal poverty line
The rules regarding illustrations apply to all group and life ins policies and certs with the following exceptions:
variable life, individual and group annuity contracts, credit life, and life ins policies with illustrated death benefits not exceeding 10k
Time payment of claim - how long do indemnities have to pay?
w/in 30 days of receipt of proof of loss (except periodics can be pd monthly)
How long does the insurer have to respond to prior auth requests?
w/in 48 hours for urgent care services and 10 calendar days for anything else
