IL Health Insurance - Illinois Statutes and Regulations Pertinent to Accident & Health Only

What services are considered limited health services?

-ambulance care -dental care -vision care -pharmaceutical -clinical laboratory services -podiatric care

What are the 10 essential benefits required by the Affordable Care Act (ACA) of all health care plans?

-ambulatory patient services -emergency services -hospitalization -maternity and newborn care -mental health and substance use disorder services, including behavioral health treatment -prescription drugs -rehabilitative and habilitative services and devices -laboratory services -preventive and wellness services and chronic disease management -pediatric services, including oral and vision care

What are the five categories of coverage in the Marketplace under PPACA?

1. Bronze 2. Silver 3. Gold 4. Platinum 5. Catastrophic

If a policyholder returns a policy within the first 30 days, to what extent will the premium be refunded?

100%. The policy must have a notice printed on the first page of the policy or attached to the policy stating that the policyholder may return the policy within 30 days of its delivery and receive a full premium refund is not satisfied for any reason (free look).

A Medicare supplement policy CANNOT deny a claim for losses incurred more than how many months from the effective date of coverage due to a pre-existing condition?

A Medicare supplement policy cannot deny a claim for losses incurred more than 6 months from the effective date of coverage due to a pre-existing condition.

Disclosure requirements for Medicare Supplements include all of the following EXCEPT A-The advertisement may apply affiliation with the Medicare program. B-Advertisements must not infer in any way that a failure to purchase a policy will affect the applicant's eligibility for Medicare. C-Advertisements must state that the Medicare Supplement is a policy sold by a private insurance company. D-The advertisement must clearly disclose the insurance company's name and address.

A. Medicare Supplement advertisements must state that the Medicare Supplement is an insurance policy sold by a private insurance company under no affiliation with the federal government or Medicare.

J has a health insurance policy that terminates when she is 12 weeks pregnant. Which of the following will most likely happen? A-Pregnancy benefits will be extended. B-J can sue the insurer to keep the policy in force. C-The original policy will be terminated, but J will be offered a limited coverage policy for a reduced rate. D-The original policy will terminate, but J will be eligible for another policy without providing proof of insurability.

A. Pregnancy benefits must be extended after coverage terminates if the pregnancy began while the policy was in force.

Which of the following individuals will be eligible for coverage on the Health Insurance Marketplace? A-A permanent resident lawfully present in the U.S. B-Someone who has Medicare coverage C-A U.S. citizen who is incarcerated D-A U.S. citizen living abroad

A. To be eligible for health coverage on the Marketplace, the individual must be a U.S. citizen or national or be lawfully present in the United States, must live in the United States, and cannot be currently incarcerated. Medicare recipients are not eligible for coverage in the Marketplace.

If a Medicare benefit is increased, a signed statement is required from the policyholder A-Only if the premium increases in response. B-Under no circumstances. C-In some states other than Illinois. D-On all occasions.

A. Unless required by law to bring the policy in line with the minimum standards required for Medicare supplement policies, any changes increasing benefits or coverage with a corresponding increase in premium must be agreed to in writing by the policyholder. If a separate premium is charged for benefits provided in connection with riders or endorsements, the charge must be set forth in the policy.

Patient Protection and Affordable Care Act (PPACA)

AKA the Affordable Care Act (ACA). Mandates increased preventive, educational, and community-based health care services

What is the maximum probationary period under a sickness policy?

Accident policies may not contain a probationary period. The probationary period under sickness policies may not exceed 6 months except for certain specified causes not treated on an emergency basis.

How long must an insurer's advertisement be kept on file?

Ads must be kept in the file for 4 years or until the company's next regular examination, whichever comes later.

All Illinois long-care insurance policies must provide LTC coverage for at least how many consecutive months?

All Illinois long-care insurance policies must provide LTC coverage for at least 12 consecutive months.

An insured receives a Medicare Supplement policy but decides not to keep it. How many days does the insured have to return the policy for a full refund of premium?

All Medicare Supplement Policies must provide a 30-day Free Look provision.

A woman obtains health coverage through the Marketplace on October 1. Two weeks later she finds out that she is 3 months pregnant. Which of the following is true about coverage for pregnancy?

All health insurance Marketplace plans must cover pregnancy and childbirth, even if pregnancy begins before the coverage takes effect.

Under standard circumstances, if a change occurs to a Medicare supplement policy that reduces benefits, which of the following must occur?

All riders and endorsements issued after the date of issue, reinstatement, or renewal that reduce or eliminate benefits or coverage require signed acceptance by the policyholder. This does not apply if the change is made upon the policyholder's request, if the insurer is exercising a specifically reserved right under the policy, or if the change is required to reduce or eliminate benefits to avoid duplication of Medicare coverage or benefits.

Other than conditions stipulated by the Director, what is a permissible reason for an HMO to cancel or not renew an enrollee's contract?

An enrollee's contract may be canceled or denied renewal when the enrollee fails to pay charges for coverage, when fraudulent misrepresentations are made in the application, when material contract violations are made, or for any other reason established by the Director.

If an individual covered under a Medicare supplement policy becomes eligible for Medicaid, how long can benefits and premiums be suspended for the Medicare policy?

Benefits and premiums under a Medicare supplement policy may be suspended for up to 24 months at the request of the policyholder if he/she becomes eligible for Medicaid. The policyholder must notify the insurer within 90 days of eligibility.

If coverage is offered as a dividend, what also must be offered as an alternative option?

Coverage may not be issued as a dividend unless a cash equivalent is also offered as an option.

According to the prohibited policy provision, all of the following are usually excluded in health insurance policies EXCEPT A-Mental or emotional disorders. B-Suicide. C-War. D-Accidents.

D. Suicide, war and mental and emotional disorders are defined as policy exclusion. Accidents will be covered.

Applications for policies advertised by what method must include a statement announcing that the policy excludes pre-existing conditions from coverage?

Direct response. If a policy excludes pre-existing conditions, applications sent with direct response ads for that policy must contain a statement certifying that applicants understand the effect of the pre-existing conditions exclusion.

How long does an HMO have to provide evidence of coverage to each subscriber?

Every HMO must provide its enrollees with a description of the services and information as to where and how to secure them. The HMO must issue evidence of coverage to each subscriber within 30 days from the effective date of coverage.

A notice stating an insured's unconditional right to return his or her policy within how many days for a full refund must appear prominently on the first page of a policy?

Except for single premium nonrenewable policies, notice of the insured's unconditional right to return the policy within 10 days for a full refund must appear prominently on the first page.

How large must a group be in order for HIPAA to apply?

HIPAA applies to groups of two or more.

Which of the following is NOT the purpose of HIPAA?

HIPAA does not prohibit employers or providers from establishing waiting periods or pre-existing conditions exclusions, in which case the coverage to new employees would not be immediate. HIPAA purpose DOES include: -To guarantee the right to buy individual policies to eligible individuals -To prohibit discrimination against employees based on their health status -To limit exclusions for pre-existing conditions

When John fills out his Medicare application, he intentionally omits his long-standing history of heart disease. Which of the following is most likely to happen?

His policy will be canceled. Except as authorized by the Department of Insurance, an insurer is not allowed to cancel or fail to renew a Medicare Supplement policy for any reason other than nonpayment of premium or material misrepresentation.

Hospital confinement indemnity coverage may not exclude emergency confinement in what type of facility?

Hospital confinement indemnity coverage may not exclude emergency confinement in a federally operated hospital.

Which of the following is generally NOT a limited health service included under an LHSO?

Limited health services include ambulance care services, dental care services, vision care services, pharmaceutical services, clinical laboratory services, and podiatric care services. Limited health care service does not include hospital, medical, surgical or emergency services except when those services are essential to the delivery of the limited health service.

Which of the following is generally a limited health service included under an LHSO?

Limited health services include ambulance care services, dental care services, vision care services, pharmaceutical services, clinical laboratory services, and podiatric care services. Limited health care service does not include hospital, medical, surgical or emergency services except when those services are essential to the delivery of the limited health service.

If an insurer plans to cancel an insured's long-term care policy because the premiums are not being paid, how much notice must be given?

No individual long-term care policy or certificate will lapse or be terminated for nonpayment unless the insurer has given to the insured and any additional designated persons at least 30 days' notice before the effective date of the lapse or cancellation.

An insured under a long-term care policy and has just been diagnosed with Multiple Sclerosis (MS). What alteration will most likely be made to the policy?

No long-term care policy may be cancelled, nonrenewed or otherwise terminated because of the deterioration of the mental or physical health of the insured.

Which of the following justifies the termination of a long-term policy?

No long-term care policy may be cancelled, nonrenewed, or otherwise terminated because of the deterioration of the mental or physical health of the insured. No individual long-term care policy or certificate will lapse or be terminated for nonpayment unless the insurer has given to the insured and any additional designated persons at least 30 days' notice before the effective date of the lapse or cancellation.

What are the licensing requirements for negotiating or soliciting coverage of a limited health service organization?

No person may apply, procure, solicit or negotiate coverage of a limited health service organization unless that person holds a valid limited insurance representative or producer license to sell accident & health insurance policies.

Under the Affordable Care Act, which classification applies to health plans based on the amount of covered costs?

Plans other than self-insured plans will be classified into four levels determined by how much of one's expected health care costs are covered. The four plans are bronze, silver, gold, and platinum. This is called metal level classification.

The Patient Protection and Affordable Care Act includes all of the following provisions EXCEPT

The Act does not offer tax deductions for health insurance premiums. The Act does offer a tax credit, which is different from a tax deduction. All the other provisions are included in the Act: -Coverage for preventive benefits. -Right to appeal. -No lifetime dollar limits.

How many accounts must the Illinois Life and Health Insurance Guaranty Association maintain?

The Association is composed of all insurers who lawfully do business in the state. It assesses members according to the lines of business they transact, and maintains 2 separate accounts: Life insurance (which includes life insurance and annuities) and Health insurance.

Which entity must approve the content of a group contract before it can be issued?

The Director must approve the form and content of a new group contract.

The Patient Protection and Affordable Care Act mandates that insurers provide coverage for adult children of the insured up to the age of ___

The law extends coverage for children of the insured to age 26, regardless of their marital status, residency, financial dependence on their parents, or eligibility to enroll in their employer's plan.

Which provision allows a new policyholder to examine a Medicare Supplement policy and return it for a full premium refund within 30 days if not satisfied for any reason?

The policy must have a notice printed on the first page of the policy or attached to the policy stating that the policyholder may return the policy within 30 days of its delivery and receive a full premium refund is not satisfied for any reason (free look).

In all health care plans under the Affordable Care Act (ACA), how many essential benefit categories are there?

There are 10 essential benefit categories under the ACA.

To be eligible under HIPAA regulations, for how long should an individual converting to an individual health plan have been covered under the previous group plan?

Under HIPAA regulations, to be eligible to convert health insurance coverage from a group plan to an individual policy, the insured must have 18 months of continuous creditable health coverage.

According to the PPACA rules, what percentage of health care costs will be covered under a bronze plan?

Under the bronze plan, the health plan is expected to cover 60% of the cost for an average population, and the participants would cover the remaining 40%.

Short-Term Limited Duration Health Insurance

any health insurance policy issued for less than one year of coverage, to fill the gap of coverage when an individual is transitioning from one health plan to another, often between jobs.

Limited Health Service Organization (LHSO)

any organization that provides limited health care plans under a system in which part of the risk of limited health care delivery is borne by the organization or its providers

catastrophic plans

available to young adults under 30 and individuals who cannot obtain affordable coverage. Catastrophic plans offer lower monthly premiums and feature high deductibles, after which the insured will have essential health benefits covered without copayment or coinsurance.

If the Director deems it so, why may an enrollee's HMO be cancelled?

n enrollee's contract may be canceled or denied renewal when the enrollee fails to pay charges for coverage, when fraudulent misrepresentations are made in the application, when material contract violations are made, or for any other reason established by the Director.

metal levels

plans that pay different amounts of the total costs of an average person's care. The actual percentage the insured will pay in total or per service will depend on the services used during the year. On average, the metal level plans cover the following amounts for each plan: -Bronze: 60% -Silver: 70% -Gold: 80% -Platinum: 90%

If a Medicare policyowner becomes eligible for Medicaid, he/she may suspend Medicare benefits for up to how many months? Within how many days must he/she notify the insurer?

suspend for 24 months; notify within 90 days