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
