Nevada Rules and Regulations pertinent to Health Only 10% Flashcards
What type of coverage is required in individual and group health insurance that covers family members of the insured.
Newborn child from moment of birth
What is covered for newborn children in health insurance policies?
injury or sickness, including necessary care and treatment of medically diagnosed congenital birth defects and birth abnormalities
What is the time period an insured has to notify the insurance company of the birth of the a newborn including payment of the required premium for coverage to continue beyond period?
within 31 days after date of birth
The same regulation for newborn children also applies to whom?
adopted children, from time of adoption or child placed in home
All health insurance can continue to provide coverage for dependents of the insured beyond the attained age stated for termination of coverage under what circumstances?
1) incapable of self-sustaining employment due to a physical handicap or intellectual disability
2) Dependent of the policyholder for support and maintenance
What are the time limits that an insured has to provide proof to the insurers of child dependency beyond age limit?
within 31 days of reaching age limit
also as often as the insurer requires afterward, no more than once a year beginning 2 years after child reaches age limit
What are the benefits provided by health insurance policies for treatment of alcoholism or drug abuse must consist of?
1) treatment for withdrawal: up to $1,500 per calendar year
2) Inpatient treatment; up to $9,000 per calendar year
3) Counseling for a person, group or family not admitted to a facility; up to $2,500 per calendar year
How are the benefits paid in the Alcohol & Drug abuse coverage?
same manner as policy would pay for any other covered illness
An insurer or other organization providing this type of coverage must comply with the provisions of what act?
Mental Health Parity and Addiction Equity Act of 2008
All health insurance that cover mastectomies must also cover what?
cover prosthetic devices and reconstructive surgery
What happens to benefits if the reconstructive surgery after a mastectomy occurs within or after 3 years?
within 3 years- benefits must equal amount provided for in the policy at the time of the surgery
after 3 years- surgery benefits are subject to current policy terms, conditions, and exclusions
What is Hospice?
facility that provides short-term, continuous care in a home-like setting to terminally ill-people (and their families) with life expenctancies of 6 months or less
Does Hospice care coverage must be included in all health insurance policies in Nevada?
Yes
A policy or certificate may not be advertised, solicited, or issued for delivery in Nevada as a Medicare Supplement policy if it contains what?
limitations or exclusions on coverage that are more restrictive than those of Medicare
Medicare policies cannot do what?
limit or reduce coverage or benefits for specifically named or descried pre-existing disease or physical conditions, and must not contains benefits that duplicate the benefits provided by Medicare
What type of minimum standards are Medicare Supplement policies subject to, as established by the Revised Statues of the Nevada Insurance code?
Some parts of the same standards of Medicare Part A and Part B, as well as Plans K and L
** See chapter for the full list of standards to long to write
In Medicare supplemental policies, noncancellable, guaranteed renewable or noncancellable AND guaranteed renewable policies cannot what?
1) Provide for termination of coverage of a spouse solely because of the occurence of an event for termination of coverage of the insured (other than nonpayment of premiums)
2) Be cancelled or denied renewal by the insurer solely on the grounds of deterioration of health
Issuer cannot cancel or refuse supplement Medicare or a certificate for any other reason except what?
Nonpayment of premiums
Material representations
Each issuer in a Medicare supplemental must provide what, to each applicant at the time application is presented to the applicant?
Outline of coverage
What must the applicant do once they receive the outline of coverage in a Medicare supplement, except in a direct response policy?
applicant must provided an acknowledgment to the issuer
What is issued when the outline of coverage at time of app and policy to supplement Medicare or certificate is issued on basis that would require revision of outline?
issued a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered
What statement is contained in the substitute outline is not less than 12-point type, immediately above name of company?
“Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued”
What must the outline of coverage in Medicare supplement include?
1) cover page
2) Information regarding premiums
3) Disclosure pages
4) Charts displaying the features of each benefit plan offered by the issuer
Every Medicare Supplement Policy must include a noticed that the insured has the right to return the policy within what time frame and be refunded any premium due if dissatisfied for any reason or choose not to purchase the policy?
30 days (free look policy)
In Nevada, what is a Long-Term care insurance (LTC)?
any group or individual policy that is advertised, marketed, or designed to provide coverage for at least 24 months for necessary diagnostic, preventative, therapeutic, rehab or medical care services provided in a setting other than an acute care unite of a hospital
What must be presented to applicant at time of initial solicitation of LTC policies?
outline of coverage
LTC’s must comply with what following provisions?
1) policies cannot terminate for a reason other than nonpayment of required premium
2) insurer cannot impose a new waiting period if the existing coverage is converted to a different coverage within same company
3) Insurer may not limit coverage to a skilled nursing care. Also may not provide significantly more coverage for skilled care provided in a facility than coverage for lower levels of care
4) policy must allow the policyholder a 30 day free look period
All long-term policies must be what?
guaranteed renewable or noncancellable
Every LTC policy must provide that in the case of lapse, insurer will reinstate the policy if insured what?
1) Proves cognitive impairment (deficiency in ability to perceive, think, reason, or remember that prevents a person from meeting daily living needs)
2) asks the insurer to reinstate the policy within 5 months of the date the coverage lapsed
3) pays any past due premiums
What required period of institutional care cannot exceed what period of time in LTC policies?
exceed 30 days
All persons who sell continuous care insurance (workers comp) must be licensed in what and approval of who?
licensed as an accident and health insurance producer and casualty insurance producer
receive approval from the Commissioner
Producers who are licensed as accident and health producers may submit written request to the Commissioner to sell continuous care coverage if they completed what?
8 hours of approved instruction in workers compensation insurance and employers liability insurance
When was the Patient Protection and Affordable Care Act (ACA for short) signed into law?
March 23, 2010 as part of Health Care and Education Reconciliation act of 2010
What is the the purpose of the ACA?
mandated increased preventative, educational, and community-based health care services
What is the ACA designed to do?
1) set up a new competitive private health insurance market
2) Hold insurance companies accountable by keeping premiums low, preventing denials and allowing applicants with pre-existing conditions to obtain coverage
3) Help stabilize budget and economy through reducing the deficit by cutting government overspending
4) Extend coverage for adult children in both individual and group health plans until age 26
What does ACA do for small businesses and nonprofits?
gives them a tax credit for an employers contribution to health insurance for employees
What does the ACA prohibit insurance companies from doing?
rescinding health coverage when an insured becomes ill
and
eliminates lifetime benefit limits
What specific health coverage plans are exempt from PPACA changes?
1) retiree-only
2) stand-alone dental plans
3) Dental Plans
4) Medigap
5) Long-term care insurance
What does the Health Insurance Marketplace do?
makes health coverage available to any uninsured individuals
To be eligible for health coverage through the Marketplace, the individual must what?
1) Must be a U.S citizen or national or be lawfully present in the U.S
2) must live in the U.S
3) cannot be currently incarcerated
When is an individual not eligible to use the Marketplace to buy a health or dental plan?
If individual has Medicare coverage
A group health plan or health insurance issuer offering group or individual health insurance coverage may not establish rules for eligibility based on any of the following health status related factors related to individuals or their dependents for what?
No discrimination for:
1) Health Status
2) Medical condition (including both physical and mental illnesses)
3) Claims experience
4) Receipt of health care
5) Medical History
6) genetic information
7) evidence of insurability (including conditions arising out of domestic violence)
8) Disability
9) any other health status related factors
What is the only 4 permitted standards that insurers can set their premium rates to?
1) Geographic rating area (location of residence within the state)
2) Family composition (single or family enrollment)
3) Age
4) Tobacco Use
What is the location for individual and small group plans for the Marketplace?
individual- insureds home address
group- employers principal place of business
What are the essential benefits for the health insurance?
Hospitalization, maternity, emergency services, wellness and preventative services, and chronic disease management
***all plans must cover pregnancy and childbirth, even if pregnancy begins before coverage takes effect for the Insurance Marketplace
In regards to ACA, what is the guaranteed issue and enrollment rules for insurance companies?
companies must accept any eligible applicant for individual or group insurance coverage
enrollment for coverage may be restricted to open or special enrollment periods
An insurance company has what types of guaranteed renewability terms for either individual or group health? under ACA regulations
must renew or continue the policy at the option of the plan sponsor or the individual
The ACA law creates a new program, the Pre-exisiting condition insurance plan that does what?
to make health insurance coverage available to individuals who have been denied health insurance by private insurance companies because of a pre-exisitng condition
If an insurer rescinds individual or group coverage for reasons of fraud or an intentional misrepresentation of material facts by the insured, they must provide at least what time frame advanced notice to allow the insured time to appeal? under ACA
30 days advance
What happens to coverage during the appeal process for an individual? under ACA
coverage in force pending outcomes of the appeal process
What ACA law extends coverage for children of the insured to age 26 regardless of what?
1) marital status
2) residency
3) financial dependence on their parents
4) eligibility to enroll in their employers plan
What are the restrictions on Health Plans for lifetime and annual limits? under ACA
restricted from applying a dollar limit on essential benefits
nor
can establish a dollar limit on the amount of benefits paid during the course of the insured lifetime
The ACA law establishes what for emergency service coverage?
emergency services must be covered even at an out-of-network provider, for amounts that would have been paid to an in-network provider for the same services
The ACA requires what for preventative benefits?
100% of preventative care be covered without cost sharing
What does preventative care include?
routine checkups, screenings, counseling, to prevent health problems
What should the group health plan ensure for cost-sharing?
must ensure that any annual-cost sharing imposed does not exceed provided limitations
The ACA has established Insurance Exchange that will do what?
administer health insurance subsidies and facilitate enrollment in private health insurance, Medicaid, and the Children’s Health Insurance Program (CHIP)
The Insurance exchanges can help an applicant do what?
1) compare private health plans
2) obtain info about health coverage options to make educated decisions
3) obtain info about eligibility or tax credits for most affordable coverage
4) Enroll in a health plan that meets the applicants needs
What are the 10 essential benefits that are required by the ACA?
1) Ambulatory patient services
2) Emergency services
3) Hospitalization
4) Maternity and Newborn care
5) Mental Health and Substance use disorder services; including behavioral treatment
6) Prescription drugs
7) Rehab and habilitative services and devices
8) Laboratory services
9) Preventative and wellness services and chronic disease management
10) Pediatric services, including oral and vision care
Under the PPACA, plans are classified into what 5 categories of coverage in the Marketplace?
4 “metal levels” plans
and
A catastrophic plan
What do the metal level plans do?
Pay percentage of total costs of an average person’s care, the insured will pay the rest of the percentage not paid
What are the metal level plans and what do they pay?
1) Bronze: 60%
2) Silver: 70%
3) Gold: 80%
4) Platinum: 90%
What must insurers offer if they offer adult and family coverage?
child-only coverage
Young adults under age 30 and individuals who cannot obtain affordable coverage (have a hardship exemption) may be able to purchase what type of plan?
individual catastrophic plans that cover essential benefits
What do catastrophic plans offer?
lower monthly premiums, but also feature high deductibles (several thousand dollars)
When does essential health benefits coverage begin in a catastrophic plan?
after insured reaches deductible then no copayment or coinsurance needed
What is the insured required to pay?
all medical costs up to a certain amount
In 2014, states were required to set up what, referred to as Marketplaces?
Affordable Insurance Exchanges
Who will the Affordable Insurance exchanges serve?
either serve
1) individuals and small businesses separately
or
2) have a combined exchange for both individual and small business clients under one organization
What is available if states choose not to build their own Marketplace and what does it do?
a Federally-facilitated Marketplace (healthcare.gov)
** helps with eligibility and enrollment, plan management, and consumer support
What is SHOP (Small business health options program) intended to do?
give small employers the same purchasing power that large employers have, opportunity to make a single monthly payment, and the ability to offer a choice of plans
Under the proposed regulations, states that choose to set up an exchange for SHOP must do what?
adopt federal standards for the program or have a state law or regulation that implements the federal standards
What will the states establish for employer participation in the exchange for SHOP?
establish insurance options for small employers participation
What is the definition of small employers under PPACA?
those with at least ONE but not more than 100 employees
Insurance exchanges may or may not do what?
May or may not have open enrollment periods for small employers
Must admit small employers whenever they apply for coverage
All employers that offer health coverage to their employees are required to provide what?
info about the PPACA and the new Heath Insurance Marketplace exchanges
What is the purpose of the employer notification?
to help employees evaluate health insurance options for them and their dependents
The Silver State Health Insurance Exchange (the exchange) is a state-based health insurance exchange that has been established for what following purposes?
1) Facilitate the purchase and sale of qualified health plans in the individual market in Nevada
2) Assist qualified small employers in facilitating the enrollment and purchase of coverage and the application for subsidies for small business enrollees
3) Reduce the # of uninsured persons in this state (Nevada)
4) Provide the transparent marketplace for health insurance and consumer education
5) Assist state residents with access to programs, premium assistance tax credits and cost-sharing reductions
The Exchange may enter into contracts with who?
any persons, including local government or agency carrying out its duties and powers
The Exchange is governed by the Board of Directors and consists of who?
7 VOTING members
3 NONVOTING members
