Plan types (indemnity, HMO, PPO, POS), cost sharing, HSAs and the ACA framework are covered in the national Medical Plans guide. This guide covers the Nebraska statutes and rules on medical expense coverage that the Accident and Health exam tests: renewability, the 10-day free look, the health claims rule (210 NAC 61) and utilization review.

Delivery, free look and renewability

• Free look. Every individual sickness and accident policy must tell the buyer they may return it within 10 days of delivery for a refund (Neb. Rev. Stat. 44-710.18). Single-premium nonrenewable policies are excepted. Medicare supplement policies follow their own 30-day rule.
• Disabled dependents. A child who can't support themselves because of a disability, and is chiefly dependent on the insured, stays covered past the limiting age if proof is given within 31 days (44-710.01(3)).
• Guaranteed renewability (44-787). Individual health coverage is renewable at the insured's option. The insurer may decline to renew only for:
  • nonpayment
  • fraud
  • discontinuing the product or leaving the market
  • certain Director findings
• Ending a product or leaving the market
  • Discontinuing a product requires 90 days' notice and an offer of the carrier's other products.
  • Leaving the whole market requires 180 days' notice. The carrier then can't write new individual business for five years.
• Creditor protection. Accident and health benefits are exempt from creditors' claims, with limited exceptions (44-371).

Health claim handling (210 NAC 61; days are working days)

• Each payment comes with an Explanation of Benefits showing the provider, the charges, the service dates and how benefits were computed.
• A penalty for not getting precertification or concurrent review can be applied only if it's clearly stated in the policy.

Utilization review (44-5401 and following)

• Utilization review agents must allow at least 24 hours after an emergency admission or service before requiring review (44-5422).
• Reviewers can't be paid based on the number of adverse determinations.
• Utilization review certificates are valid for two years (44-5419).

Unfair practices that touch health coverage

• Who counts as an insurer. HMOs, prepaid limited health service organizations and dental plans are insurers under the Unfair Trade Practices Act (44-1523(6)).
• Blindness. Refusing, limiting or surcharging coverage solely because of blindness or partial blindness is unfair discrimination (210 NAC 35).
• Different classes of plans. Different rates or benefits are allowed for group, family, franchise or blanket plans, but not unfair discrimination between people of substantially the same hazard (44-749).
• Lead generators. Health insurance lead generators keep records, including call recordings, for the current year and the two years before (44-1525(13)).

Small groups

A small employer for Nebraska's small-group law has at least two and no more than 50 eligible employees (44-5253).

Required individual policy provisions (grace periods, notice of claim, reinstatement) are covered in the Nebraska Individual Accident and Health Provisions guide. State continuation is covered in the Nebraska Group Health Insurance guide.

Common exam traps

• Nebraska's individual A&H free look is 10 days. Single-premium nonrenewable policies are excepted.
• Health claims deadlines are 15 working days: acknowledge, investigate, decide, pay.
• Leaving the individual market means a five-year ban on new business there.
• Utilization review must allow 24 hours after an emergency.