Free Medical Plans Study Guide
Hawaii Accident & Health exam — Medical Plans.
The national guide covers medical plan design: HMOs, PPOs, POS plans, deductibles, coinsurance, copays, out-of-pocket maximums and HSAs. Hawaii's state questions on medical plans focus on two things: the benefits Hawaii law requires health policies to include (HRS Article 431:10A) and the prompt-pay rules for health plans (HRS 431:13-108). Employer-mandated coverage under the Prepaid Health Care Act is covered in the Group Health Insurance guide.
National concepts in brief
- HMO: prepaid, network-only care, with a primary care physician acting as gatekeeper for referrals. Providers are often paid by capitation (a fixed amount per member).
- PPO: lower cost sharing in network, with out-of-network care still covered at a higher cost.
- POS: a blend of the two, with a primary care physician coordinating care.
- Cost sharing: deductible first, then coinsurance or copays, up to the out-of-pocket maximum.
- A qualified high-deductible plan can be paired with a health savings account.
Mandated benefits in Hawaii
These mandates are in the accident and health article of the Insurance Code. Learn each one with its number.
| Mandate | Hawaii rule |
|---|---|
| Newborns | Family coverage applies from the moment of birth, including congenital defects. If extra premium is due, the insurer may require notice and payment within 31 days (HRS 431:10A-115) |
| Adopted newborns | Coverage starts at birth if written notice of intent to adopt is given before the birth or within 30 days after (HRS 431:10A-116(5)) |
| Child health supervision | Covered from birth through age five, 12 visits, no deductible; immunizations are free of copayments (HRS 431:10A-115.5) |
| Mammography | Annual screening mammogram from age 40, and earlier with a personal or close family history on a doctor's recommendation (HRS 431:10A-116(4)). No referral may be required for women 40 and older (HRS 431:10A-116.2) |
| In vitro fertilization | Policies with pregnancy benefits include a one-time outpatient IVF benefit when there is at least five years of infertility or a listed condition and other treatments have failed (HRS 431:10A-116.5) |
| Autism | Diagnosis and treatment for covered persons under 14. Applied behavior analysis may be capped at $25,000 a year for ages 13 and under (HRS 431:10A-133) |
| Medical foods | Medical foods and low-protein modified foods for inborn errors of metabolism, covered at at least 80% of cost (HRS 431:10A-120) |
| Diabetes | Outpatient self-management training, equipment and supplies in comprehensive medical policies. Limited-benefit, specified disease, Medicare supplement and LTC policies are exempt (HRS 431:10A-121) |
| Optometry | If a policy pays for a vision service an optometrist may lawfully perform, it pays whether a physician or an optometrist performs it (HRS 431:10A-116(1)) |
| Adult children | Dependent coverage for children must be available until age 26 (HRS 431:10A-141) |
| Disabled dependents | A disabled, dependent child stays covered past the limiting age if proof is given within 31 days (HRS 431:10-212) |
Genetic information
Health insurers may not use or require genetic information to deny, limit or price accident and health coverage (HRS 431:10A-118). The rule does not apply to life, disability income or long-term care insurance.
Prompt payment of health claims
HRS 431:13-108 sets deadlines for health insurers, mutual benefit societies and HMOs:
| Step | Deadline |
|---|---|
| Pay a clean, uncontested claim filed on paper | 30 calendar days |
| Pay a clean, uncontested claim filed electronically | 15 calendar days |
| Notice that a claim is contested or denied | 15 days (paper) / 7 days (electronic) |
| Interest on late claims | 15% a year |
| Recouping an overpayment from a provider | Must start within 18 months of payment (72 months for fraud), after 30 days' written notice |
Other Hawaii points
- Unfair claims rules apply to health claims too. Insurers must answer claim communications within 15 working days and pay within 30 days of accepting liability (HRS 431:13-103(a)(11)).
- Wellness program rewards are not illegal rebates if total rewards stay within 20% of the cost of coverage (HRS 431:13-103(a)(9)(E)).
- If a health insurer becomes insolvent, the Hawaii Life and Disability Insurance Guaranty Association covers basic hospital, medical and surgical or major medical benefits up to $500,000 (HRS 431:16-203).
Common exam traps
- The mammogram mandate starts at 40, and no referral may be required.
- Autism coverage runs to under 14, with ABA capped at $25,000 for ages 13 and under.
- Newborn notice is 31 days; adoptive notice is 30 days.
- Electronic clean claims are paid in 15 days, paper claims in 30. Late interest is 15%.
- The genetic information ban does not reach disability income or LTC.
Practice Medical Plans questions All Accident & Health topics
Practice questions are study aids generated for exam preparation and are not actual exam questions. Content is provided for educational purposes and is not legal advice. Verify current statutes, rules, and exam specifications with the Insurance Department and the exam administrator before relying on it.
