Common Health Insurance Requirements Flashcards
Major medical in the individual market must be at least…
Guaranteed renewable
Major medical in the individual market must continue at policyholder’s option regardless of…
Claims or individual health status
Major medical in the individual market can still be canceled or non-renewed for…
Nonpayment, fraud, or moving out of the service area
Major medical in the individual market premiums can go up but…
Mist be done for entire rate class, not on a case by case basis
Noncancelable
Even premiums can’t change other than pre-scheduled increases
Pre-Existing Conditions
Health conditions discovered/treated prior to insurance’s issue date
Pre-existing periods often have a look-back period of…
6 months or 2 years
Pre-existing conditions might only be covered after…
An extended waiting period, if at all
ACA major medical plans generally cannot discriminate on the basis of…
Pre-existing conditions or exclude them
Health insurers can still exclude types of care if…
They do it for everyone with the same plan/type of policy
Common Health Insurance Exclusions
Elective cosmetic surgery, dental care, eye exams and glasses, war injuries, experimental treatments, alternative medicine, workplace injuries/illnesses, custodial care, care needed after committing a crime, care needed after intoxication
Eligible dependents can enroll in an insured person’s group plan during…
Open enrollments or when they lose their insurance, if the plan accepts dependents
ACA plans must continue covering children until…
26, longer if disabled
Newborn children are automatically covered for…
31 days after birth regardless of health
Pregnancy Discrimination Act
Requires maternity coverage for group plans of 15 or more
Group plans cannot treat pregnancy as a…
Pre-existing condition
ACA plans for smaller groups and in individual market must cover…
Maternity care
Mental Health Parity
Group plans with 50 or more people generally must cover mental health care similarly to physical care
Most ACA plans, individual and group, must cover mental health care without…
Annual or lifetime caps
Genetic Information Nondiscrimination Act (GINA)
Prohibits insurers from discriminating on the basis of genetics in major medical insurance
Genetic discrimination in other products (life, disability, LTC) is addressed at what level?
State
COBRA stands for…
Consolidated Omnibus Reconciliation Act
COBRA
Lets former employees and dependents keep group coverage for 18 months (36 months for dependents who lose coverage due to health or divorce)
COBRA Deadline
60 days
COBRA applies to only…
Group major medical, dental, and vision insurance with 20 or more members
COBRA: Insured person must pay…
Entire premium plus 2% for admin expenses
Affordable Care Act (ACA)
Sets standards/requirements for most forms of major medical insurance
ACA: Employers with how many employees must have a health plan?
50 or more
ACA: Individuals who lack employer coverage might be eligible for…
Subsidized coverage in federal “exchange”/marketplace
ACA: Prohibits discrimination due to…
Pre-existing conditions, if enrolling during certain enrollment periods
ACA: Premiums for individuals and small groups only differ by…
Age, geography, and tobacco use
ACA: Children can stay on parent’s insurance until…
26
ACA: Generally has no cost-sharing for…
Preventative care
ACA: Must cover what with no lifetime or annual limits?
Essential health benefits
ACA: Essential Health Benefits
Most common procedures and forms of treatment
ACA: No rescission except in case of…
Extreme fraud
