Health Insurance Provisions Overview

Other Provisions and Clauses in Health Insurance

• Uniform Mandatory Provisions must be included in all individual health insurance policies.
• Insuring Clause identifies the agreement between the insurance company and the insured, detailing coverage and responsibilities.
• Free Look provision allows insured to review the policy for a specified number of days (commonly 10) and return it for a full refund if unsatisfied.
• Consideration Clause establishes that both parties must provide valuable consideration; the insured pays premiums, and the insurer promises coverage.
• Probationary Period requires a waiting time before coverage for specific conditions is activated, often seen in disability income policies.
• Elimination Period acts as a deductible in disability policies; benefits are payable only after a specified number of days post-incident.
• Waiver of Premium provision waives future premiums during total disability after a waiting period, typically 3 to 6 months.

Pre-existing Conditions

• Pre-existing conditions refer to health issues treated prior to applying for coverage.
• The Affordable Care Act eliminated pre-existing condition restrictions in most health insurance plans, but exceptions exist for disability and long-term care.

Coinsurance and Cost Sharing

• Coinsurance provisions dictate shared expenses, commonly with the insurer covering about 80% after the deductible is met.
• Variations of coinsurance arrangements can include 90/10 or 75/25 percentages to influence premium costs.
• Stop-loss limits prevent excessive out-of-pocket expenses; once reached, the insurer covers 100% of remaining costs.

Additional Cost Sharing Mechanisms

• Copayment provisions specify a fixed amount the insured pays for services, differing from coinsurance.
• Deductibles are amounts required to be paid by the insured before benefits kick in; can vary as individual, family, or per occurrence deductibles.
• Integrated deductibles can satisfy amounts across different covered services within a policy year.

Exclusions and Limitations

• Exclusions denote causes of loss not covered by the policy, including war, self-inflicted injuries, and cosmetic procedures.
• Temporary suspensions of coverage may occur for insureds residing abroad or serving in the military.
• Mental and emotional disorders often have limited coverage benefits and visit allowances, distinct from inpatient treatment provisions.

Eligible Expenses and Approval Requirements

• Eligible Expenses encompass covered medical costs as outlined in the policy.
• Pre-authorization may be required for certain procedures to ensure coverage approval prior to the service.

Benefit Limits

• Maximum Benefit Limits determine the ceiling on policy payouts, categorized as lifetime, annual, or per-cause limits.
• Lifetime limits cap total payouts over the insured's life, while annual limits restrict amounts per year. Per-cause limits apply to expenses for related health issues.

Explore the key provisions and clauses that individual health insurance policies must include. This quiz covers the mandatory provisions required by state regulations as well as additional provisions that insurers can incorporate. Test your understanding of the framework governing health insurance policies.