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Insurance Underwriting > Chapter 7: Colorado Statues, Rules, and Regulations for Sickness & Accident Insurance > Flashcards

Chapter 7: Colorado Statues, Rules, and Regulations for Sickness & Accident Insurance Flashcards

1
Q

What are 5 types of coverage and benefits that must be on all individual and group sickness and accident insurance policies?

A
  1. Essential Health Benefits
  2. Maternity and Newborn Coverage
  3. Mammography and Prostate Screenings
  4. Diabetes
  5. Hospice and Home Health Care
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2
Q

What are the 10 essential benefits required for all health care plans according to the Affordable Care Act (ACA)?

A
  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 and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management; and
  10. Pediatric services, including oral and vision care
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3
Q

Under PPACA, plans are classified into 5 categories of coverage in the Marketplace: four “metal level” plans and catastrophic plans. How do the metal levels work?

A

The metal levels plans pay different amounts of the total costs of an average person’s care.

Bronze: 60%
Silver: 70%
Gold: 80%
Platinum: 90%

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4
Q

What kind of coverage is available for young adults under the age of 30 and individuals who cannot obtain affordable coverage?

A

Catastrophic Coverage

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5
Q

What does catastrophic coverage cover?

A

The essential benefits

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6
Q

How does catastrophic coverage work?

A

Insureds pay a lower monthly premium but have a high deductible, after the deductible is reach the insurance company pays the rest of the loss with no copayments or coinsurance.

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7
Q

True or False: Under the ACA, premium discounts may be awarded to low-income individuals, regardless of the chosen metal levels.

A

True

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8
Q

Can a pregnancy be considered a pre-existing condition?

A

No.

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9
Q

What is the minimum number of hours an insurance company cover for a hospital stay for a normal vaginal birth?

A

48 hours

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10
Q

What is the minimum number of hours an insurance company cover for a hospital stay following a cesarean section?

A

96 hours

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11
Q

When are newborns covered by their parents insurance plan?

A

Moment of birth

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12
Q

How long is the newborn covered by their parents plan without paying an individual premium and deductible for the newborn?

A

31 days

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13
Q

Are mammographies fully covered under preventative care?

A

Yes and are not subject to policy deductibles, copayments, or coinsurance.

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14
Q

Are prostate screenings covered?

A

Yes, but they may have a charge associated with them that can be no more than $65.

Not subject to deductible

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15
Q

Is diabetes coverage guaranteed?

A

Yes as mandated by the ACA but benefits for treatment of diabetes are subject to the same annual deductibles or copayments

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16
Q

What is the maximum amount an insured can pay for a 30-day supply of insulin?

A

$100

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17
Q

How long is a terminally staged patient expected to live?

A

No more than 6 months

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18
Q

How long is the benefit period for hospice care?

A

90 day limit

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19
Q

How many days are mandated by the ACA for home health care?

A

At least 60 days required

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20
Q

True or False: All sickness and accident insurance policies issued in the state of Colorado must include coverage for alcoholism.

A

True

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21
Q

True or False: All sickness and accident insurance policies issued in the state of Colorado must include coverage for

A

True

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22
Q

True or False: All sickness and accident insurance policies issued in the state of Colorado must include coverage for child health supervision services.

A

True

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23
Q

True or False: All sickness and accident insurance policies issued in the state of Colorado must include coverage for hospitalization and general anesthesia for dental procedures for dependent children.

A

True

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24
Q

True or False: All sickness and accident insurance policies issued in the state of Colorado must include coverage for prosthetic devices.

A

True

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25
Q

True or False: All sickness and accident insurance policies issued in the state of Colorado must include coverage for cervical cancer vaccines.

A

True

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26
Q

True or False: All sickness and accident insurance policies issued in the state of Colorado must include coverage for hearing aids for children.

A

True

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27
Q

How long does a certified early intervention service broker have to notify the insurer that a child (up to age 3) is eligible for early intervention services?

A

10 days

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28
Q

How long does the insurer have to pay benefits into a trust established by the Colorado Department of Human Services (CDHS)?

A

30 days

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29
Q

How long does the Division for Developmental Disabilities have to notify the insurer that a child is no longer eligible for early intervention services?

A

90 days

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30
Q

How often are new hearing aids covered?

A

5 years

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31
Q

What is a clean claim?

A

The term clean claim means a claim for payment of health care expenses that is submitted to a carrier on the uniform claim form with all required fields completed with correct and complete information, including all required documents.

32
Q

What is an unclean claim?

A

A claim requiring additional information is considered an unclean claim.

33
Q

How long do the insurers have to resolve a clean claim?

A

30 calendar days (electronically)

45 calendar days (submitted by other means)

34
Q

How long do insurers have to resolve unclean claims?

A

90 days and if not there is a penalty in an amount equal to 20% of the total amount ultimately allowed on the claim

35
Q

How long does a covered individual have to request an independent external review after receiving notification of a denial of coverage?

A

4 months

36
Q

Define: Entire contract/changes

A

The policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. Policy changes will not be valid until approved by an executive officer of the insurer and unless such approval be endorsed or attached. Producers have no authority to change the policy or to waive any of its provisions.

37
Q

Define: Time limit on certain defenses

A

After 2 years from the date of issue of a policy, no misstatements made by the applicant in the policy application (except in the cases of fraud) can be used to void the policy or to deny a claim for loss incurred or disability beginning after the expiration of a 2-year period.

38
Q

Define: Grace Period

A

In policies other than health benefit plans, 7 days for weekly premium policies, 10 days for monthly premium policies, and 31 days for all other modes will be granted for the payment of each premium falling due after the first premium. The policy will continue in force during the grace period. (see additional grace period requirements for individual and small employer plans below)

39
Q

Define: Reinstatement

A

If any renewal premium is not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or its producer, without requiring an application for reinstatement, will reinstate the policy. If the insurer or producer requires an application for reinstatement and issues a conditional receipt for the premium received, the policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the 45 day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application.

40
Q

Define: Notice of claim

A

Written notice of claim must be given to the insurer within 20 days after the occurrence of any loss covered by the policy or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to any authorized producer of the insurer will be deemed notice to the insurer.

41
Q

What are claim forms provision?

A

Upon receipt of a notice of claim, the insurer must furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice, the claimant will be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character, and the extent of the loss for which claim is made.

42
Q

What is the proofs of loss provision?

A

Written proof of loss must be furnished to the insurer within 90 days after the date of such loss.

43
Q

What is the time of payment of claims provision?

A

Indemnities payable under this policy for any loss will be paid immediately upon receipt of due written proof of such loss.

44
Q

What is the legal actions provision?

A

No action at law will be brought to recover on a policy prior to the expiration of 60 days after written proof of loss has been furnished. No such action will be brought after the expiration of 3 years after the time written proof of loss is required to be furnished.

45
Q

What is the change of beneficiary provision?

A

Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries will not be required to surrender, make any change of beneficiary or beneficiaries, or to any other changes in this policy.

46
Q

How long is the grace period for individuals and small employer health benefits plans for persons receiving a subsidy under the federal act?

A

3 months

47
Q

If the insureds are not receiving a subsidy under the federal act, the policies must have a grace period of how many days?

A

31 days

48
Q

When can a person purchase coverage if they want their coverage to start on January 1?

A

On or before December 15 of the open enrollment period

49
Q

When can a person purchase coverage if they want their coverage to start on Feb 1?

A

December 16 through January 15 of the open enrollment period

50
Q

When can a person purchase coverage if they want their coverage to start on March 1?

A

January 16 through January 31 of the open enrollment period.

51
Q

How long must the special enrollment period be?

A

60 Days

52
Q

What does an agent have to supply to an insured who is looking to replace their coverage with another plan BEFORE the policy can be issued?

A

A notice Regarding Replacement

53
Q

How many days of notice do the insurance company need to give the insured that they are terminating their policy?

A

30 Days’ Notice

54
Q

How many months can an employee stay on their employers group insurance after they have been terminated?

A

18 months

55
Q

how long does the employer have to notify the terminated employee that they have the right to continued health care coverage Upton termination from employment?

A

10 days

56
Q

Can the employee continue health care coverage from the employer after termination and beyond the 18 month group coverage?

A

Yes, but the employee must pay for it and they will be under an individual plan

57
Q

How many employees must a business have in order to be considered a small employer?

A

1-50

58
Q

Does an employee have to be full time to be eligible for insurance?

A

yes

59
Q

What is the annual open enrollment period for small group coverage?

A

October 15 through December 7

60
Q

What are the four case characteristics that carriers consider when determining premium rates for individuals and small employers?

A
  1. The age of covered individuals
  2. Geographic location of the policyholder
  3. Family size
  4. Tobacco use.
61
Q

What is the maximum number of days an employer can require a new employee to work before they offer health coverage?

A

90 Days

62
Q

What needs to be given to the applicant at the time of application when applying for supplementary Medicare coverage?

A

Outline of Coverage

63
Q

How long is the free look period for Medicare supplement policies?

A

30 days

64
Q

After how much time is a loss not considered a pre-existing condition when claimed on a medicare supplemental policy?

A

6 months from the effective date of coverage

65
Q

How much time does an insured have to inform the insurer that they are suspending their medicare supplement plan because they are getting medicaid?

A

90 days

66
Q

When is a shopper’s guide and outline of coverage presented to the would-be insured?

A

Before the agent gives them the application

67
Q

Define pre-existing condition

A

Pre-existing condition means a condition for which medical advice or treatment was recommended by or received from a provider of health care services within 6 months preceding the effective date of coverage of an insured person.

68
Q

How long is the free look for an individual LTC insurance policy?

A

30 days

69
Q

In which types of plans are inflation protection found?

A

Long term care insurance policies

70
Q

Define: Twisting

A

knowingly making any misleading representation or incomplete or fraudulent comparison of any insurance policies or insurers for the purpose of inducing, or tending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on or convert any insurance policy or to take out a policy of insurance with another insurer.

71
Q

Define: High pressure tactics

A

Employing any method of marketing having the effect of or tending to induce the purchase of insurance through force, fright, threat, whether explicit or implied, or undue pressure to purchase or recommend the purchase of insurance.

72
Q

Define: Cold lead advertising

A

Making use directly or indirectly of any method of marketing which fails to disclose in a conspicuous manner that a purpose of the method of marketing is solicitation of insurance and that contact will be made by an insurance producer or insurance company.

73
Q

How many ADL must be compromised before an LTC policy will pay out benefits?

A

3

74
Q

How many hours of training must a producer complete in order to receive a LTC license?

A

16 training hours, 8 of which are specific to LTC

75
Q

How long does the insurance company have to inform the insured that their claim has been denied?

A

15 days

76
Q
A

Insurance Underwriting (7 decks)

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