Free Medical Plans Study Guide
Indiana Accident & Health exam — Medical Plans.
The national guide covers medical plan design:
- plan types: HMOs, PPOs and POS plans;
- cost sharing: deductibles, coinsurance, copays and out-of-pocket maximums;
- HSAs and the ACA.
Indiana's state questions on medical plans focus on mandated coverages, prompt pay, grievances and external review, CHIP, and the ACA rules that appear on the exam.
ACA facts the Indiana exam uses
- Metal levels: the plan pays about 60% (Bronze), 70% (Silver), 80% (Gold) or 90% (Platinum) of covered costs.
- Catastrophic plans: available to people under 30, or to those with a hardship or affordability exemption.
- Essential health benefits:
- Every Marketplace plan covers them, including mental health and substance use services.
- Pediatric dental and vision are essential benefits; adult dental and vision are not.
- Preventive services: most plans cover a set of preventive services at no cost to the enrollee.
- Agents: to sell on the Marketplace, agents complete CMS registration and training every plan year, in addition to holding a state license.
Indiana coverage rules
| Rule | Indiana |
|---|---|
| Dependents | Coverage for a child until 26, on request (IC 27-8-5-28) |
| Disabled dependents | Coverage continues past the limiting age with proof within 31 days. Proof may be required periodically for two years, then no more than once a year (IC 27-8-5-2) |
| Newborns | Covered from birth, including congenital defects and cleft lip and palate treatment. Notice and premium may be required within 31 days (IC 27-8-5.6) |
| Adopted children | Covered from the earlier of placement or a custody order, with no preexisting condition or insurability limits (IC 27-8-5-21) |
| Mammography | A baseline at 35–39, and annual screening from 40. Women under 40 who are at risk get annual screening (IC 27-8-14-6). Non-employer policies must offer this coverage |
| Genetic testing | Insurers may not require genetic testing, ask for its results, or use the results to set premiums or limit coverage (IC 27-8-26) |
| HIV | No benefit maximum or exclusion limited only to HIV or AIDS, except in specified-disease policies. Testing requires written consent. Questions designed to find out sexual orientation are prohibited (760 IAC 1-39) |
Prompt pay (IC 27-8-5.7)
- Clean claims are paid or denied within 30 days if filed electronically and 45 days if filed on paper. Late payments earn interest.
- Deficiencies: an insurer that doesn't notify the provider of problems with a claim within those same periods must treat the claim as clean.
Grievances and external review
- Grievances (IC 27-8-28):
- The insurer acknowledges a grievance within 5 business days.
- It resolves the grievance within 20 business days, or 10 more if the delay is beyond its control.
- External review (IC 27-8-29):
- Requested in writing within 120 days of the appeal decision.
- Only one external review is allowed per appeal decision.
Indiana CHIP
- Who qualifies: children under 19, Indiana residents, in families with income above 150% and up to 250% of the federal poverty level (IC 12-17.6-3-2).
- Renewals: families need not resubmit eligibility information more than once every 12 months.
Common exam traps
- Indiana prompt pay is 30 days for electronic claims and 45 days for paper.
- External review must be requested within 120 days, not four months.
- Newborn notice is due within 31 days. Adopted children are covered from placement.
- Mammograms: baseline at 35–39, then annual from 40.
- Insurers can't require genetic testing or use its results.
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.
