Health Insurance Policy Provisions and Managed Care
Uniform mandatory provisions
Entire contract; time limit on certain defenses (two years); grace period (7 days for weekly premium, 10 days for monthly, 31 days otherwise); reinstatement; notice of claim (about 20 days); claim forms (insurer must furnish within 15 days); proof of loss (90 days); time of payment of claims (immediately or within 30 days); physical examination at insurer expense; legal actions (three years); change of occupation; misstatement of age; illegal occupation; unpaid premium; conformity with state law.
Optional provisions
Change of occupation, misstatement of age, other insurance in this insurer, unpaid premium, and cancellation. These may appear in some policies but are not mandatory.
Managed care mechanics
- HMO - closed panel, PCP gatekeeper, capitation, no non-emergency out-of-network coverage.
- PPO - discounted network, out-of-network allowed at higher cost, no gatekeeper.
- POS - hybrid; in-network care needs a referral, out-of-network allowed with higher cost sharing.
- EPO - network only, but no PCP gatekeeper.
Utilization tools: preauthorization, concurrent review, discharge planning, case management, and retrospective review.
Rule of thumb
Memorize the grace period by premium mode - 7 / 10 / 31 - and remember legal action = 3 years, proof of loss = 90 days, claim forms = 15 days. These are the most common distractors.
Traps
HMO emergency care is covered anywhere; the network restriction applies to non-emergency treatment. A preexisting-condition exclusion is limited by federal and state rules, so a question offering an unlimited exclusion period is wrong.