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65 Cards in this Set
- Front
- Back
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Credible coverage for portability (credit for pre-existing conditions) include
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Medicare A&B
Medicaid Individual Health Benefit Group health Military sponsored health Indian Health Service CoverColorado Health benefit under peace corp |
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No new pre-existing period applies when
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coverage is continuous with no more than a 90 day gap
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Mom and baby must be covered for how long after birth
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48 hours for vaginal birth
96 hours after cesarean section |
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When may an employer elect to self-insurer for pregnancy?
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any number of full or part time employees in less than 15 full-time positions
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How are mammography screens insured?
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must provide lessor of $103.50 or actual cost
No deductible or co-insurance (may be subject to co-pay) |
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What are the common breast cancer risk factors that required breast cancer screenings to be covered?
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- being 40 or over
- family history of breast cancer - genetic predisposition to breast cancer |
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When must prostate screenings be paid for?
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- men over 50
- men between 40 and 50 with high risk factors |
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What must be paid for an annual prostrate screen?
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- must provide $65 or actual charge with no deductible
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When must "clean" claims be paid?
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- must be paid, denied or settled withing 30 days after receipt if submitted electronically
- 45 days if submitted otherwise |
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When must non-"clean" claims be paid?
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within 90 days of receipt
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what are the interest requirements on claims not paid timely?
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- 10% annually from time claim should have been paid
- plus 20% penalty of the total amount ultimately paid - beginning to acrue from 91st day after claim was received. |
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If a claim is denied due to lack of medical necessity, what kind of a review process must exist if the client chooses it?
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- first level internal review within 20 days
- second level internal review with a panel of at least 3 people - |
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How long does the client have to request an external review?
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with 60 calendar days of receiving notification of second level internal denial
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How long does the expert external review entity have to submit their determination?
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30 days
(7 working days if an expedited request) |
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What are schizophrenia, schizoaffective disorder, bipolar, major depressive disorder, specific obsessive compulsive disorder, and panic disorder?
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biologically based mental illness
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What are PTSD, drug and alcohol disorders, dysthymia, cyclotheymia, social phobia, agoraphobia with panic disorder, and general anxiety disorder?
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Mental disorders
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When must therapies for congenital defects and birth abnormalities be covered?
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from a child's third to sixth birthdays
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When are health insurance producers required to disclose commissions?
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At the time of sale
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How long must records related to commission sale disclosure be maintained?
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3 years
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What is the grace period for premiums paid monthly?
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10 days
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What is the grace period for premiums paid weekly?
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7 days
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What is the grace period for premiums paid less frequently than monthly?
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31 days
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When does automatic reinstatement of health insurance policy happen?
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after 45 days if he/she doesn't hear from the insurer
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How long is the probationary period after health insurance reinstatement?
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10 days
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When must notice of claim be given?
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20 days
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How soon must insurers provide claims forms?
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15 days
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How many the insured provide proof of loss if now claims forms are provided?
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Any written proof
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What does Time Payment of claims require?
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that the insurer pay covered claims promptly
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How often must disability payments be made?
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monthly
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What does the physical exam and autopsy provision allow?
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the insurer, at it's own expense, to examine the insured as often as necessary during a period of claim and to conduct an autopsy to verify accidental death (AD&D)
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What does the legal actions provision state?
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no insured may bring lawsuit against insurer after the expiration of 3 years from the time proof of loss what furnished
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What are the optional provisions?
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- Change of occupation
- misstatement of age - relation of earnings to insurance - coordination of benefits |
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What must the producer provide when determining that a health insurance sale would involved replacement?
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The "notice" must be provided at time of application to be signed by the applicant
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How long must copies of the health insurance replacement notice be kept?
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at least 2 years
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How long is the pre-existing condition / probationary period?
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-6 months from effective date for group
-12 months for individual |
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How is a preexisting condition defined?
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An injury or sickness for which a person incurred charges, received medical treatment, consulted a health care professional or took perscription drugs within:
- 6 months immediately preceding effective date of coverage for group - 12 months immediately preceeding for individual |
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When do small group coverages not apply?
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If you are a business group of one that includes only a self-employed person with no employees, or a sole proprietor who is not covering employees and you choose to purchase individual coverage
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If a sole-proprietor or a business group of one buys an individual policy - what does the disclosure form have to state?
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- They understand that by their purchase of individual health plan instead of small group, they may lose their right to purchase small group coverage for 3 years after date of purchase
- how benefits differ - how the different rates are set |
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What does the group health continuation provision state?
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continuation may be up to 18 months
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How long do employees have to have been covered by a group plan to be eligible for continuation?
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6 months
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What does the group health conversion provision state?
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employees may convert to an individual policy by the same insurer within 31 days of termination without evidence of insurability
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How long do employees have to have been covered by a group plan to be eligible for conversion?
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3 months
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What benefits must be provided for mental illness?
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at least 45 days for inpatient or 90 days for partial hospitalization within any 12 month benefit period
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What are the requirements for alcoholism coverage on group health policies?
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- must be given option to purchase
- if accepted, must provide at least 45 days of inpatient care - out patient benefits must be a minimum of $500 - deductible must be the same as for any other illness - co-insurance may be as high as 50% |
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What is a late enrollee?
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an eligible employee or dependent who requests enrollment in a group health benefit plan following the initial enrollment period - if such initial enrollment period is a period of at least 30 days
- had creditable coverage during the enrollment period - lost coverage due to acceptable event |
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How soon does a late enrollee need to request enrollment?
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within 30 days after termination or a court order, or after becoming a dependent
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What is a small employer?
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one that on at least 50% of its working days in the preceding quarter employed no more than 50 eligible employees fr
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How many hours does an eligible employee need to work?
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24 hours or more
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business group of one
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individual, sole proprietor or a single employee with significant business activity for at least one year
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Which is better standard or basic? Which costs more?
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standard are better than basic
standard costs more |
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What rating factors may be used for small group health?
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age
geographic area family composition tobacco plan design standard industrial classification |
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What are the stipulations of small employer tobacco based premium discounts?
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discount not to exceed 15% for those who have refrained for more than 12 months prior
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how does a basic plan compare to a standard plan?
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basic plans have nearly the same benefits but with higher co-insurance, co-pays, and deductibles.
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Medicare max probationary period?
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6 months
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When applying for medicare... producers must five applicants what?
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Outline of coverage
copy of the "guide" |
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What is the medicare free look period?
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30 days
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What the requirements for Medicare renewability and cancelation?
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All policies must be guaranteed renewable and may not be canceled solely on the basis of health status
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How long does a LTC policy need to provide coverage?
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for not less than 12 consecutive months in a nursing home
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how long are group LTC policies convertible to individual LTC policies?
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31 days
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What is the maximum probationary period for LTC?
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6 months from date policy issued
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What is a federally eligible employee?
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they must have had creditable coverage for 18 months or more and whose most recent policy was a group
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Max lifetime benefit on CoverCO?
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$1 million
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What is the primary difference between CoverCO and GettingUsCovered?
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Getting us covered requires no insurance for the previous 6 months.
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How long must records relating to commission disclosure be kept on file?
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3 years from date of sale
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When must health insurance commissions be disclosed?
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at time of sale
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