Health specific Laws

Question 1

Medicare supplement insurance:

medicare supplement insurance must

Answer 1

prominently disclose that the policyholder has the right to return the policy or certificate within 30 days of its delivery for a full refund of premium if the insured is not satisfied for any reason.

Question 2

Preexisting conditions:

A medicare Supplement may not

Answer 2

deny coverage for preexisting conditions for more than 6 months after the effective date of coverage.
1 time in lifetime

Question 3

In home sales

A producer selling a medicare supplement in a purchaser’s home must

Answer 3

give the purchaser his/her name, address, and telephone number, and the insurer’s name
Complete, in the purchaser’s presence, a Policy Checklist in duplicate. The Policy checklist must be signed and given to the purchaser and insurer. The insurer must maintain a copy on file at its administrative office.

Question 4

An insurer providing Medicare Supplements must:

Answer 4

Annually file its rates, rating schedule, and other documentation demonstrating that it complies with loss ratio standards of Illinois
Submit a copy of any Medicare Supplement advertisement to the Director for review

Question 5

An advertisement describing Medicare must

Answer 5

State that the insurer and agent are not connected with the Medicare program
Disclose that it is an insurance advertisement
Identify the insurer’s actual address
Indicate that a failure to respond will not jeopardize medicare coverage
State if one of the insurer’s representatives will deliver any material or information in person

Question 6

A medicare supplement may not:

Answer 6

Limit or exclude coverage more restrictively than Medicare does except for preexisting conditions
Use waivers to exclude, limit, or reduce coverage or benefits for specifically named preexisting diseases or physical conditions.
Duplicate benefits provided by Medicare

Question 7

A medicare supplement insurer may not deny coverage to an applicant

Answer 7

under 65 years of age who meets any of the following criteria:
Becomes eligible for Medicare by reason of disability if the person makes application for a Medicare supplement policy within 6 months of the first day on which the person enrolls for benefits under Medicare Part B.
Has Medicare and an employer group health plan that terminates or ceases to provide all such supplemental health benefits
Is insured by a Medicare Advantage or medicare supplement policy and the insurer goes out of business, withdraws from the market, or the insurer or agents misrepresent the plan and the applicant is without coverage

Question 8

Benefit standards:

A medicare supplement must

Answer 8

Coincide with any changes in the applicable Medicare deductible amount and copayment percentage factors
Be guaranteed renewable: increase premium by a class but must renew

Question 9

A medicare supplement may not

Answer 9

Exclude or limit coverage for preexisting conditions for more than 6 months after the effective date of coverage
Define the term preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage
Indemnify against losses resulting from sickness on a different basis than losses resulting from accidents
Terminate spousal coverages solely because the insured’s coverage terminates, except for nonpayment of premium

Question 10

An insurer may not cancel or nonrenew a Medicare Supplement

Answer 10

Solely because of an individuals health status

For any reason other than nonpayment of premium or material misrepresentation

Question 11

Long-Term Care insurance

any health policy or rider advertised, marketed, offered, or designed to provide coverage for at least

Answer 11

12 consecutive months for each covered person

Question 12

Traditional Long-term care
Preexisting condtions
A Long-term care policy may not

Answer 12

deny coverage for preexisting conditions for more than 6 months after the effective date of coverage.

Question 13

Prohibited provisions

An LTC policy may not

Answer 13

Be terminated on the grounds of the insured’s age or deterioration in health
Establish a new waiting period when converting or replacing coverage within the same company, except for a benefit increase that the insured voluntarily selects
Cover skilled nursing care only or provide significantly more coverage for skilled care in a facility than coverage for lower levels of care.

Question 14

prior institutionalization

An LTC policy may not:

Answer 14

Condition eligibility for any benefits on a prior hospitalization requirement
Condition eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care.
Condition eligibility for any benefits other than waiver of premium, post-confinement, post-acute care, or recuperate benefits on prior institutionalization.
Require a prior institutional stay of more than 30 days if conditioning eligibility for noninstitutional benefits on the prior receipt of institutional care
Condition eligibility for benefits upon admission to a facility for the same or related condition within fewer than 30 days after discharge from the institution if providing benefits only following institutionalization.

Question 15

The free-look period on LTC policies is

Answer 15

30 days, subject to a premium refund

Question 16

An outline of coverage must

Answer 16

be delivered to an applicant during the initial solicitation.

Question 17

An LTC policy must be delivered to the

Answer 17

applicant within 30 days after the underwriter date of approval. Claim denial must be accompanied by written reasons for denial.

Question 18

Illinois long-term are partnership program
The Illinois long-term care partnership program is administered by the department of healthcare and family services with the assistance of the department of insurance to do the following

Answer 18

provide incentives for individuals to insure against the costs of providing for their LTC needs
Provide a mechanism for individuals to qualify for coverage of the cost of their LTC needs under medicaid without first being required to exhaust their assets.
Provide counseling services to individuals planning for their LTC needs
Alleviate the financial burden on the State’s medical assistance program by encouraging the pursuit of private initiatives
dollar for dollar benefit payout

Question 19

If an individual is a beneficiary of the Partnership certified policy

Answer 19

the total assets an individual owns and may retain under medicaid and still qualify for benefits under Medicaid at the time the individual applies for LTC benefits increased by $1 for each $1 of benefit paid out under the individual’s certified policy

Question 20

Advertising: Form and Content

A health policy’s ad format and content must

Answer 20

be complete and clear and avoid deception. The Director determines whether an ad has the capacity or tendency to mislead or deceive.

Question 21

No ad may use words or phrases in a manner

Answer 21

that exaggerates any benefits beyond the terms of the policy

Question 22

Testimonials and endorsements must

Answer 22

be genuine, up to date, and authorized by the endorser

Question 23

Advertisement may

Answer 23

not make comparisons that are unfair or disparaging to other organizations.

Question 24

Record Keeping

Each insurer must keep all ads on file in its office for

Answer 24

4 years or until the next Department examination. Also, each insurer must file a certificate of compliance with ad regulations with its annual statement.

Question 25

minimum standards for individual policies:
Prohibited provisions
No individual policy may

Answer 25

establish a waiting period, except for sickness (30 days) or non-emergency hernia, varicose veins, adenoids, appendix and tonsils (6 months).

Question 26

Accident policies may not

Answer 26

contain a probationary or waiting period

Question 27

A policy may be issued as a dividend only if

Answer 27

an equivalent cash payment is offered to the policyholder as an alternative to such dividend policy or rider. No such dividend may be issued for an initial term of less than 6 months.

Question 28

A disability policy, hospital confinement indemnity policy or specified disease policy may contain a cash value benefit only if it

Answer 28

provides return of 100% of all premiums paid, less the claims incurred, by the time the insured attains age 65.

Question 29

Benefit standards

A guaranteed or non-cancelable policy may not

Answer 29

terminate coverage for a spouse except for nonpayment premium

Question 30

Basic hospital expense coverage must provide

Answer 30

at least 80% of the charges for semi-private room accommodations, or $100 per day (may be reduced to $70 outside the metropolitan area).

Question 31

Basic Medical-surgical expense coverage must

Answer 31

provide for no less than 80% of the reasonable charges.

Question 32

Major Medical Expense Coverage may provide

Answer 32

an aggregate maximum of no less than 10,000

Question 33

Accident only coverage must

Answer 33

provide accidental death and double dismemberment benefits of at least 1,000, with single dismemberment at least 500.

Question 34

Disclosure

The individual policy must state:

Answer 34

Right of return for full premium for any reason (free look) within 10 days
A renewal, continuation, or nonrenewal provision on the first page
Preexisting condition limitations, if any
That it does not cover sickness, if it is an accident only policy

Question 35

A rider or endorsement reducing coverage must

Answer 35

be signed by the policyholder in order to be valid if added after the issue date

Question 36

An outline of coverage must

Answer 36

be delivered to all applicants
Detail the policy’s coverages, terms, renewability, expectations, reductions, and limitations
State the insurer’s name and address

Question 37

Replacement

An application must

Answer 37

determine whether coverage is intended to replace another healthy policy in force.

Question 38

If a sale involves replacement, the insurer must

Answer 38

give the applicant a Notice Regarding Replacement, before issuing or delivering the policy, which states that certain factors may affect the protection available under the new policy, including preexisting conditions

Question 39

Group insurance
Discontinuance and replacement
Group policies issued in Illinois must

Answer 39

provide a reasonable extension of benefits and benefits payable under such extension may be subject to the policy’s regular benefit limits.

Question 40

An insurer who is discontinuing a group policy, shall

Answer 40

notify persons of the discontinuance effective date an encourage them to avail themselves of any contract rights.

Question 41

A group policy replacing a discontinued policy shall

Answer 41

cover all persons who are covered under the plan being replaced.

Question 42

The replaced insurer shall

Answer 42

be liable only for its accrued liabilities and extension of benefits.

Question 43

The prior insurer shall

Answer 43

provide extension of benefits for an insured’s disabling condition when no coverage is available under the succeeding insurer’s plan

Question 44

Extension of benefits
For hospital and medical expenses coverages and HMO plans, other than dental, pharmaceutical or other limited expense coverages, such extension will be

Answer 44

considered ‘reasonable’ if it extends coverage until the earliest of the following:
The end of 12 months or
the date the maximum benefit is reached or
the end of total disability

Question 45

For other types of hospital or medical expenses plans, such as

Answer 45

those limited to hospital expenses only, medical expenses only, or surgical expenses only, such an extension will be considered reasonable if it extends coverage until the earliest of the following:
90 days or
the date the maximum benefit is reached or
the end of total disability

Question 46

An extension of benefits need not

Answer 46

be provided when an individuals coverage terminates under the group contract in accordance with the contract’s eligibility and termination provisions.

Question 47

Total disability means

Answer 47

A covered person’s inability to perform his/her regular or customary occupational duties because of injury or disease
After benefits have been paid for 24 months, the covered person cannot perform the duties of any gainful occupation for which he/she is reasonably fitted by training, education, or experience
For dependents or retired employees, the inability because of injury or disease to engage in substantially all of the normal activities of a person in good health of like age and sex

Question 48

If a policy is discontinued because of non-payment of premium, the insurer shall

Answer 48

still be liable for valid claims incurred prior to the end of the grace period.

Question 49

The discontinuance effective date shall not

Answer 49

be prior to midnight at the end of the third scheduled word day after the date upon which the discontinuance notice is delivered.

Question 50

Requirements for notice of discontinuance

Covered individuals must

Answer 50

be notified within 10 working days of the policy owner being notified of discontinuance, and advised that the insurer will not be liable for claims incurred after the discontinuance date.

Question 51

If the premium for the group plan being discontinued involve employee contributions and the policy holder continued to collect such contributions after the discontinuance date, the employer

Answer 51

shall be solely liable for benefits applicable to the period for which employee contributions were collected

Question 52

Unfair practices
Discrimination
insurers may not discriminate between individuals of the same risk class in regards to:

Answer 52

policies issued, renewed, or cancelled
The amount of premiums or rates charged
the benefits payable
any of the terms or conditions
any other manner whatsoever

Question 53

Insurers are not prohibited from providing

Answer 53

incentives for insureds to use the services of a particular hospital or person

Question 54

Further, the terms “physician” or “doctor” shall include

Answer 54

persons licensed to practice dentistry under the Illinois Dental practice act

Question 55

No company, in any accident or health policy shall

Answer 55

make or permit any distinction or discrimination against individuals solely because handicaps or disabilities, except where the distinction or discrimination is based on sound actuarial principles or is related to actual or reasonably anticipated experience.

Question 56

No company shall refuse to insure, nor limit the

Answer 56

coverage extent or amount available to an individual, or charge an individual a different rate for the same coverage solely because of blindness or partial blindness.

Question 57

persons who are blind or partially blind shall

Answer 57

be subjected to the same standards of sound actuarial principle or actual or reasonably anticipated experience as are sighted persons.

Question 58

Refusal to insure includes

Answer 58

an insurer’s denial of disability insurance coverage on the grounds that the policy defines “disability” as being presumed in the event that the insured loses his or her eyesight.

Question 59

a qualified clinical cancer trial payment may not be based, in whole or in part,

Answer 59

on the person’s having or not having coverage for routine patient care under a group policy.

Question 60

Coverage is not required for out of network services

Answer 60

where the underlying health benefit plan does not provide for such services.

Question 61

routine patient care means all health care services which would

Answer 61

normally be provided outside of a qualified cancer trial

Question 62

routine patient care does not include, and a group policy may exclude coverage for:

Answer 62

a health care service item or drug that is the subject of the qualified cancer trial
A health care service, item, or drug provided solely to satisfy qualified cancer trial’s data collection and analysis needs
An investigational drug or device that has not been approved for market by the US FDA
Transportation, lodging, food, or other expenses for the patient, a family member, or companion of the patient that are associated with the qualified clinical cancer trial, unless the policy normally covers these expenses
A health care service, item, or drug customarily provided by the qualified clinical caner trial sponsors free of charge for any patient
A health care service or item, which is otherwise specifically excluded from coverage
Costs for services, items, or drugs that eligible for reimbursement from a source other than a patient’s health policy
costs associated with approved cancer clinical trials designed exclusively to test toxicity or disease pathophysiology, unless the policy normally covers these expenses

Question 63

Illinois health insurance portability and accountability act (HIPPA), which applies to healthy policies and services in Illinois supersedes

Answer 63

any conflicting, inconsistent, or less restrictive legal standards or requirements

Question 64

A group health plan may impose

Answer 64

a preexisting condition exclusion for a period of not more than 12 months (or 18 months in the case of late enrollee) after enrollment, reducible by any applicable creditable coverage (prior coverage which ended less than 63 days before the enrollment date of the new policy)

Question 65

Pregnancy and genetic info may not

Answer 65

be classified as preexisting condition

Question 66

Discrimination is prohibited on the basis of

Answer 66

health status
medical condition
claims experience
receipt of health care
medical history
genetic information
evidence of insurability
disability

Question 67

group plans are

Answer 67

guaranteed renewable

Question 68

Managed care

An organization formed to provide health care plans

Answer 68

under a system that causes any health care risk to be borne by the organization or its providers.

Question 69

An HMO must:

Answer 69

Maintain a process for resolving grievances about its health care delivery system and its operation
submit its grievance process to the Director for pre approval
maintain a record of each filed grievance for at least 3 years after its resolution
Authorize a grievance committee, which must hear and resolve submitted grievances within 60 days of receipt
Have a complaint resolution procedure
Respond to a complaint received by the Department within 21 days after receiving notice of the complaint
Issue a contract or other evidence of coverage to each subscriber or enrollee
Issue a contract or other evidence of coverage to each subscriber or enrollee
Provide coverage for mental and emotional disorders

Question 70

An HMO may not cancel a contract because of

Answer 70

the enrollee’s health status or use of the HMO’s grievance system

Question 71

A contract issued by an HMO may not restrict services because

Answer 71

the enrollee or any covered dependent receives medicaid benefits

Question 72

An HMO must cover the

Answer 72

full expense, without applying a deductible or coinsurance, of any medical examination of a victim of sexual assault

Question 73

Group contracts must be

Answer 73

renewable and must provide health care services for at least 12 months.

Question 74

However, the HMO may nonrenew the contract by

Answer 74

giving the contract owner at least 31 days written notice

Question 75

HMO producers must meet

Answer 75

licensure requirements

Question 76

Illinois health maintenance organization guaranty association
The association protects of HMO health care plans against

Answer 76

insurer insolvency

Question 77

All insurers authorized to sell HMO policies must

Answer 77

be members of the association

Question 78

If a member becomes insolvent,

Answer 78

the other members are assessed the necessary funds to cover the insolvent insurer’s claims

Question 79

The Association may not be held liable for more than

Answer 79

the insolvent insurer’s contractual obligations, up to 500,000

Question 80

Limited health service organization (LHSO) is an organization providing

Answer 80

limited health care plans under whose risk is borne by the organization or its providers

Question 81

Limited Health services available through an LHSO include

Answer 81

Ambulance
Dental
Vision care services
Pharmaceutical services
Clinical laboratory services
Podiatry care

Question 82

An LHSO must issue each subscriber or enrollee a

Answer 82

group contract or evidence of coverage within 30 days from the effective date or the date that the organization is notified of the its enrollment

Question 83

Group contracts must be

Answer 83

renewable and must provide limited health services for at least 12 months. however the LHSO may nonrenew the contract or other evidence of coverage by giving the contract or certificate owner at least 31 days written notice.

Question 84

The complaint procedure for LHSO’s is the complaint procedure for

Answer 84

HMO’s

Question 85

A person soliciting LHSO coverage must hold

Answer 85

either a limited insurance representative’s license or a health producer’s license

Question 86

The director may require an LHSO to submit

Answer 86

ads for approval 30 days before use for 12 months if the LHSO has used a false or misleading ad.