Insurance Policy Replacement & Spousal Coverage

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Questions and Answers

What is the minimum benefit level provided by a succeeding policy when replacing a prior group insurance policy?

Determined by the insurance administrator.

Higher than the prior policy's benefit level.

The same as the former plan's benefit level minus any benefits already paid. (correct)

Equal to the prior policy's benefit level.

Under what condition can a legally separated spouse continue coverage under COBRA?

If they notify the administrator within 30 days of separation.

Only if they were the primary certificate holder.

If written notice is given within 60 days of legal separation. (correct)

Coverage cannot continue under COBRA for legally separated spouses.

What must occur for a new insurance policy's coverage to terminate?

The insurance company decides to stop the coverage.

The individual does not pay the premium on time.

The individual becomes eligible under the new plan. (correct)

The individual's health condition worsens.

What happens to the ongoing claims under a new policy when replacing an old insurance policy?

They are paid under the new policy despite any exclusions. Signup and view all the answers

At what age must a surviving spouse be to continue coverage after the death of the certificate holder?

55 years or older. Signup and view all the answers

Under what condition can a group health insurance policy not be converted to an individual policy?

The individual did not make timely payments. Signup and view all the answers

What is the maximum time allowed for a long-term care policy to have an effective date before coverage starts due to prior conditions?

6 months Signup and view all the answers

What must LTC insurance associations provide to the Director regarding their organization?

Evidence that they comprise at least 100 persons. Signup and view all the answers

What is the maximum duration that non-institutional benefits can require prior institutional care under long-term care policies?

30 days Signup and view all the answers

What happens if a claim is denied under a long-term care policy?

The reason must be explained within 60 days. Signup and view all the answers

What requirement must be met for an insurer to be considered a long-term care provider?

Offer coverage lasting at least 12 consecutive months. Signup and view all the answers

What conduct is explicitly prohibited under state law regarding insurance practices?

Making misleading representations or fraudulent comparisons of insurance policies. Signup and view all the answers

How long does the Director have to decide on the acceptance of evidence filed by LTC insurance associations?

30 days Signup and view all the answers

What is a key characteristic of a blanket policy?

It automatically covers unspecified individuals within a group. Signup and view all the answers

Which of the following is true regarding small employer group health plans?

They must be renewable with specific exceptions. Signup and view all the answers

What is the maximum employee count for an entity to be classified as a small employer?

50 employees Signup and view all the answers

What requirement must health benefits plans for small employers comply with?

They cannot require participation levels greater than specified percentages. Signup and view all the answers

Which group is NOT an eligible entity for group health insurance policies in Missouri?

Individual contractors Signup and view all the answers

Study Notes

Group Policy Replacement

Individuals not continuously covered under a group policy for months before termination can be covered under a similar policy.
The new policy must begin within 31 days of termination, with first month's premium and application within 31 days.
Replacement policies must provide at least the same benefits as the old policy, reduced by any benefits covered under the previous policy.
Coverage in a replacement policy continues until the earliest of these dates: individual's new eligibility date, original policy termination date, or disability ending date.
The minimum level of benefits is the applicable level payable by the carrier.

Spousal Coverage

Surviving spouses aged 55 or older at the policy's expiration can continue coverage (hospital, medical, expenses).
Legal separations or divorces are eligible for similar continuation options.
Dental, vision, and prescription drug coverage can also be continued for legal separations or divorces and surviving children as previously offered.
COBRA (Consolidated Omnibus Budget Reconciliation Act) applicable for legal separation or divorce continuation coverage; written notice within 60 days is required.
If the individual is legally separated or divorced, the policy must specify how such coverage will be handled under COBRA.

Blanket Policies

This section discusses blanket policies, but more detail is needed to summarize it fully.
A group health policy does not need to be available to an individual if the individual's group coverage failed to make timely payments.
If the former group policy is terminated under the COBRA (Consolidated Omnibus Budget Reconciliation Act) provision, the former group policy benefits under the new policy that replaces the former group policy are not affected, and the new policy continues to the same terms as the former policy until the expiration of the former policy coverage period.

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Description

This quiz covers the essentials of group policy replacements and spousal coverage under insurance plans. Understand the requirements for continuous coverage, the process of applying for replacement policies, and the options available for surviving spouses and separated individuals. Test your knowledge on these important insurance concepts.