Health Policy Provisions, Consumer Protections, and Government Health Plans
Statutory provisions
Renewability: cancellable, optionally renewable, conditionally renewable, guaranteed renewable (no individual cancellation; class rates may rise), and noncancellable (rates and renewability guaranteed). Free look of 10 days. Grace period, commonly 7 days for weekly, 10 days for monthly, and 31 days for other modes. Reinstatement restores coverage with a new contestable period. Incontestability and the time limit on certain defenses bar denial after two years except for fraud. Claim rules: notice within 20 days, proof of loss within 90 days, payment within 30 days, and legal action only after 60 days. Change of occupation and illegal occupation clauses reduce benefits; overinsurance provisions refund excess premium; subrogation and coordination of benefits prevent double recovery.
Consumer protections
HIPAA portability and privacy (creditable coverage, certificates, protected health information); Mental Health Parity; Newborns' and Mothers' Health Protection Act; Women's Health and Cancer Rights Act (reconstructive surgery); continuation coverage after a qualifying event (commonly 18 months for termination, 29 months for disability, 36 months for dependents); ACA internal appeals and external review; and prohibitions on twisting, rebating, and misrepresentation.
Government plans
Medicare Part A (hospital), B (medical), C (Medicare Advantage), D (prescription drugs). Medigap supplements Original Medicare and generally cannot be sold to someone enrolled in Medicare Advantage. Medicaid is income-tested and state-administered; CHIP covers children; Social Security disability pays cash, not medical bills; TRICARE and VA serve military families.
Worked example: A premium due June 1 with a 31-day grace period keeps the policy in force through July 1, so a claim in that window is paid. Trap: Medicare Advantage and Medigap are alternatives, not partners.