INDIVIDUAL MARKET HEALTH INSURANCE COVERAGE MODEL REGULATION

What this document is

INDIVIDUAL MARKET HEALTH INSURANCE COVERAGE MODEL REGULATION is a naic model law published by National Association of Insurance Commissioners (NAIC). It is one of the documents that insurance license exam questions are written from, including life & health practice questions. This page summarizes it and points to the official version, which is the text to rely on.

Sections cited in practice questions

Each practice answer shows the exact passage it comes from. These are sections of this document that questions cite, with a short excerpt from the source text.

• Section 12C

  “C. (1) A health benefit plan providing essential health benefits must have procedures in place that allow an enrollee to request and gain access to clinically appropriate drugs not covered by the health benefit plan. (2) (a) The procedures must include a process for an enrollee, the enrollee’s...”

• Section 14F

  “F. Emergency department services must be provided as follows: (1) Without imposing any requirement under the health benefit plan for prior authorization of services or any limitation on coverage where the provider of services is out of network that is more restrictive than the requirements or...”

• Section 16A(5), 16B and 16C

  “(5) Covers only individuals who meet either of the following conditions: (a) Have not attained the age of thirty (30) years prior to the first day of the policy year; or (b) Have received a certificate of exemption for reasons identified in Section 1302(e)(2)(B)(i) or (ii) of the Federal Act. B. A...”

• Section 6E(1)(a)

  “(1) (a) In addition to the special enrollment periods provided in Section 9B of the Act and qualifying events, as defined under Section 603 of ERISA, a health carrier must provide special enrollment periods for the following triggering events: (i) An individual or dependent loses minimum essential...”

• Section 6E(2)(b) and 6E(2)(c)

  “(b) Except as provided in Subparagraph (c) of this paragraph, for a health benefit plan selection received by the health carrier from an individual: (i) Between the first and fifteenth day of any month, the health carrier must ensure a coverage effective date of the first day of the following...”

• Section 7C(3)

  “(3) Other types of modifications made uniformly are considered a uniform modification of coverage if the individual market health insurance coverage for the product meets all of the following criteria: (a) The product is offered by the same health carrier, as that term is defined in Section 3B of...”

• Section 7E

  “E. (1) Nothing in this section should be construed to require a health carrier to renew or continue in force individual market health insurance coverage for which continued eligibility would otherwise be prohibited under applicable federal law. (2) Medicare eligibility or entitlement to such...”

• Section 9A(3)

  “(3) Nothing in this section prohibits a health carrier from establishing more favorable rules of eligibility for individuals with an adverse health factor, such as a disability, than for individuals without the adverse health factor.”

Practice this material

Questions about this source

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