A&C Colorado complete Flashcards
What must group accident and health policies issued in Colorado cover concerning maternity?
Normal pregnancy and childbirth expenses
This rule does not apply to employers with fewer than 15 full-time employees or certain self-insured options.
What is the minimum hospital stay coverage for a newborn after a normal vaginal delivery?
48 hours
Coverage must continue until 8 am if the 48-hour period ends after 8 pm.
What is the minimum hospital stay coverage for a newborn after a cesarean section?
96 hours
Coverage must continue until 8 am if the 96-hour period ends after 8 pm.
What must accident and health policies provide for newborn children?
Benefits from the moment of birth
This includes coverage for injury, sickness, congenital defects, and dental care for cleft lip and/or palate.
Define ‘complication of pregnancy’ in terms of health insurance coverage.
Any disease, disorder, or condition adversely affected by or caused by pregnancy that requires supervision and results in loss or expense covered by the policy.
List four preventive health care services that must be covered by health policies in Colorado.
- Alcohol misuse screening and counseling
- Cervical cancer screening
- Breast cancer mammography screening
- Cholesterol screening
What is the coverage requirement for diabetes in health insurance policies?
Coverage for diabetes, including equipment, supplies, and education
This applies except for supplemental policies covering specified diseases.
What is the minimum number of home health visits covered per calendar year?
60 visits
Home health services must be provided by a certified agency.
What is the definition of ‘terminally ill’ in terms of hospice care?
Having a life expectancy of six months or less.
What must health policies provide coverage for regarding hearing aids?
Hearing aids for minor children with verified hearing loss
Coverage includes initial and replacement hearing aids, assessment, fitting, adjustments, and training.
What are essential health benefits as defined in the federal Patient Protection and Affordable Care Act?
- Ambulatory patient services
- Emergency services
- Hospitalization
- Laboratory services
- Maternity and newborn care
- Mental health and substance abuse disorder services
- Pediatric services
- Prescription drugs
- Preventive and wellness services
- Rehabilitative and habilitative services
Under what circumstances can an insurer refuse to renew a health benefit plan?
- Nonpayment of premium
- Fraud or intentional misrepresentation
- Discontinuing similar benefit plans
- Non-compliance with participation rules
- No enrollees in a managed care plan
- Policyholder ceases to be a student
- Employer ceases membership in an association
What is the required payment timeline for uncontested claims?
Paid, denied, or settled within 30 days if submitted electronically; within 45 days if submitted by other means.
What is the penalty for claims not paid, denied, or settled within 90 days?
20% of the total amount ultimately allowed on claims.
What is the maximum amount a covered person must pay for prescription insulin drugs?
$100 per 30-day supply.
What is the purpose of utilization review in health care?
To evaluate the clinical necessity, appropriateness, or efficiency of health care services.
What must a health carrier do for adverse determinations made during a hospital stay?
Continue health care services without liability until notified.
What is the maximum time frame for a health carrier to make a determination for urgent care requests?
72 hours.
What must be included in a written notification of an adverse determination?
- Principal reasons and medical basis for determination
- Specific plan provisions
- Description of additional information needed
- Internal rule or guideline relied on
- Instructions for appeal
What must a health carrier provide regarding the benefit request?
Written procedures outlining the reason for the information, internal rules or guidelines, appeal instructions, and request for clinical rationale
This includes a two-level internal review process for appeals.
Under what conditions may a health carrier not deny a claim for emergency services?
If a prudent layperson reasonably believed an emergency medical condition existed and if prior authorization was not secured
This applies even if the care is provided by a noncontracting provider.
What is a standard appeal in the context of health carrier determinations?
A written procedure for reviewing an adverse determination initiated by the covered person or their representative
This process must not jeopardize the life or health of the covered person.
What must a health carrier notify a covered person about regarding external reviews?
Their right to request an external review, including procedures and opportunity to submit new information
This notification must occur at the time of the final adverse determination.
Which of the following is NOT considered an essential health benefit?
Long-term care services
Essential health benefits include emergency services, maternity care, and prescription drugs.
What is the grace period for individual health benefit plans for policyholders receiving federal tax credits?
Three months starting from the first month premium is not received
The policyholder must have paid at least one full month’s premium during the current benefit year.
What must applications for individual accident and health policies include?
A question about whether the insurance will replace any other health insurance
This is to ensure transparency regarding policy replacement.
What are triggering events that allow for special enrollment periods?
- Involuntary loss of existing coverage
- Loss of pregnancy-related Medicaid
- Loss of dependent status
- Gaining a dependent through marriage, civil union, birth, or adoption
Special enrollment periods last for 60 days following a triggering event.
What is the definition of a small employer according to Colorado law?
Any business with an average of 1 to 100 eligible employees during the preceding calendar year
The employer must not have been formed primarily for purchasing insurance.
What is required for an employee to continue health coverage after employment termination?
The employee must elect to continue coverage, have paid premiums until termination, and have been continuously covered for at least six months
The employer must notify the employee of this right.
What type of mental illnesses must be covered by health policies?
Biologically based mental illnesses and mental disorders
Coverage must be no less extensive than for physical illnesses.
What must a health carrier do if a policyholder’s premium payment becomes delinquent?
Provide at least a 30-day advance notice of cancellation
This notice must clarify that termination does not qualify for a special enrollment period.
What are the requirements for small group coverage?
- Premium or benefit paid by a small employer
- Eligible employee reimbursed by a small employer
- Premiums receive favorable federal tax treatment
- Employees solicited through an employer
These requirements do not apply to multiple employer plans or newly issued individual plans covering a business group of one.
What is the definition of a premium in the context of small group coverage?
All money paid by a small employer and eligible employees for coverage
This includes fees and contributions associated with a health benefit plan.
What is guaranteed issue in health benefit plans?
Each carrier must issue any applicable health benefit plan to any eligible individual who applies and agrees to make required premium payments.
What coverage must a carrier offer to applicants under 21 years of age?
Child-only plan coverage on a guaranteed-issuance basis during open enrollment.
What must a carrier offering small employer health benefit plans do?
Issue plans to all eligible employees and their dependents who apply for enrollment during eligibility.
A carrier may restrict enrollment to _______ or special enrollment periods.
[open]
What is the maximum waiting period a carrier can apply for small employer health benefit plans?
90 days.
What factors must be considered uniformly among all small employers when determining coverage?
Minimum participation of eligible employees and minimum employer contributions.
What is a triggering event for special enrollment periods?
Involuntary loss of existing creditable coverage.
What happens if a carrier denies coverage due to insufficient financial reserves?
Coverage cannot be offered until 180 days after denial or until financial reserves are sufficient.
True or False: A carrier must provide coverage based on an individual’s health status.
False.
What is the purpose of Medicare supplement insurance?
To fill gaps created by Medicare deductibles and copayments.
Medicare supplement policies must be _______ renewable.
[guaranteed]
What must Medicare supplement policies not exclude regarding preexisting conditions?
Benefits for losses incurred more than six months after the effective date of coverage.
What is the current number of standardized Medicare supplement plans available?
10.
A carrier must provide a summary of benefits and coverage form effective from when?
January 1, 2014.
What demographic characteristics are considered case characteristics for premium rates?
- Age of covered individuals
- Geographic location
- Family size
- Tobacco use
What must a carrier not do in relation to marketing health benefit plans?
Engage in unfair practices based on health status, claims experience, or geographic location.
What must happen if a Medicare supplement policy is terminated by a group policyholder?
The insurer must offer certificate holders the option to select an individual Medicare supplement policy.
What should be provided to buyers upon solicitation of Medicare supplement policies?
The ‘Guide to Medicare Supplement Policies.’
How many standardized Medicare supplement plans are currently available?
10
These plans range from basic core policies to those with more comprehensive coverage.
What document must producers provide to buyers upon solicitation of a Medicare supplement policy?
Guide to Medicare Supplement Policies
This guide contains essential information about the policies available.
True or False: Medicare supplement plans duplicate benefits provided under Medicare.
False
Each Medicare supplement plan provides supplemental coverage, not duplicate benefits.
What is the open enrollment period for Medicare supplement policies for individuals aged 65 or older?
Six months
This period begins with the first month an individual enrolls in Medicare Part B.
What conditions can lead to an insurer denying a Medicare supplement policy application during the open enrollment period?
None
Insurers cannot deny or condition the issuance of a policy based on health status or medical conditions.
What is the maximum duration for excluding coverage for preexisting conditions in a Medicare supplement policy?
Six months
Coverage may be excluded for conditions treated or diagnosed within six months prior to the policy’s effective date.
True or False: All riders or endorsements that reduce benefits in a Medicare supplement policy require signed acceptance by the insured.
True
There are exceptions for certain riders or endorsements requested by the insured.
What must insurers provide at least 30 days before the effective date of any Medicare benefit changes?
Notification of modifications
Insurers must inform their insureds about changes to policies and premium adjustments.
What must be included in the outline of coverage for Medicare supplement insurance?
Description of benefits, exceptions, renewal provisions, and a summary statement
This outline helps applicants understand their coverage better.
What is the free-look period for Medicare supplement policies?
30 days
Purchasers can return the policy for a full refund within this period if unsatisfied.
What is prohibited in advertisements for Medicare supplement insurance?
Exaggerated claims
Advertisements must not use misleading terms like ‘comprehensive’ or ‘unlimited’ to describe benefits.
True or False: An individual can have more than one Medicare supplement policy.
False
The sale of multiple Medicare supplement policies to an individual is prohibited.
What is the definition of a long-term care insurance policy?
Coverage for at least 12 months for necessary services in non-acute settings
This includes diagnostic, preventive, therapeutic, rehabilitative, or custodial services.
What marketing standards must insurers follow when marketing long-term care policies?
Fair comparison, no excessive insurance, and clear disclosures
These standards ensure transparency and protect consumers.
What must be included in the outline of coverage for long-term care policies?
Description of benefits, exclusions, renewal provisions, and summary statement
These items help applicants make informed decisions.
What does a Policy Summary for long-term care insurance include?
Explanation of benefits interaction, exclusions, and illustrations of benefits
This summary informs the policyholder about their coverage.
What is the purpose of the free-look period in long-term care insurance?
To allow the purchaser to return the policy for a full refund if not satisfied
This right must be made clear to the policyholder.
How is the renewability of long-term care insurance policies regulated?
Must be at least guaranteed renewable provisions
Insurers cannot have less favorable renewal terms unless authorized by the commissioner.
What triggers benefits in long-term care insurance policies?
Ability to perform ADLs and cognitive impairment
Policies must base payment on deficiencies in these areas.
What are the activities of daily living (ADLs) required for long-term care policies?
- Bathing
- Continence
- Dressing
- Eating
- Toileting
- Transferring
These activities help determine eligibility for benefits.
What limitations are permitted in long-term care insurance policies?
- Preexisting conditions
- Mental or nervous disorders
- Treatment in government facilities
- Services covered by Medicare
- Services by immediate family
Certain exclusions are allowed under Colorado law.
True or False: Long-term care policies can exclude coverage based on the insured’s age.
False
Policies cannot be terminated based on age or deterioration of health.
What is required for home health care services to be covered under a long-term care policy?
The insured must first or simultaneously receive nursing care, therapeutic services, or both in a home or community setting.
This ensures that home health care services are contingent upon prior care being provided.
What types of services are limited to coverage under home health care policies?
Coverage is limited to services provided by:
* Registered nurses
* Licensed practical nurses
This restriction ensures that only qualified professionals provide care.
True or False: A long-term care policy can require hospitalization before paying benefits.
False.
A long-term care policy may not condition benefits on prior hospitalization.
What happens to benefits if a policy is terminated while the insured is institutionalized?
The insurer may not stop paying benefits as long as the institutionalization continues without interruption.
Benefits may be limited to the duration of the benefit period or maximum benefits.
What must group long-term care insurance in Colorado provide upon termination?
It must provide a basis for continuation of coverage or conversion to an individual policy with similar benefits.
This applies without evidence of insurability.
What is required for a long-term care insurance policy to be considered compliant regarding renewability?
The policy must clearly state the duration of renewability and coverage.
This ensures transparency in policy terms.
What inflation protection options must long-term care insurers offer?
Options must include:
* Annual increases of at least 5%
* Periodic increase rights without evidence of insurability
* Coverage of a specified percentage of actual charges
These options protect policyholders from inflation impacts on long-term care costs.
What must long-term care insurance application forms include regarding replacement policies?
They must ask whether the proposed policy will replace any existing coverage.
This helps prevent gaps in coverage and ensures informed decisions.
What is subrogation in the context of insurance?
Subrogation is the transfer to the insurer of the insured’s right of recovery against others.
This allows the insurer to recover costs from the responsible party after compensating the insured.
What is the penalty for violating Colorado law regulating long-term care insurance?
Fines up to three times the amount of commissions paid for each policy involved, or up to $10,000, whichever is greater.
This is in addition to other disciplinary measures.
What is the minimum continuing education requirement for selling long-term care insurance in Colorado?
Producers must complete a one-time training course of at least 16 hours and continuing education every 24 months.
The training must focus on long-term care insurance and partnership plans.
What is the Colorado Long-Term Care Partnership Program designed to do?
It allows individuals to protect assets from spend-down requirements under Medicaid.
This partnership benefits both the insured and the state Medicaid program.
What must health insurance advertisements accurately describe?
Exceptions, exclusions, and conditions not covered.
This ensures transparency and prevents misleading information.
What is the purpose of the Summary of Benefits and Coverage form?
To provide clear information about health benefit plans, including deductibles and covered services.
This form helps consumers understand their coverage options.
True or False: Health insurers must reimburse for medical costs incurred if a workers’ compensation dispute exists.
True.
Health insurers must pay until the workers’ compensation status is determined.
