Required policy provisions: newborn and chemical-dependency coverage

Question 1

Under Texas law, when an individual accident and health policy covers the insured's family members, when does coverage for a newborn child of the insured begin?

Accepted Answer

From the moment of birth

Answer

On the date the insurer approves an application for the child

Answer

On the 31st day after the date of birth

Answer

On the date the child is discharged from the hospital in good health

Question 2

If continued coverage of a newborn depends on payment of an additional premium, by when may the policy require the insured to notify the insurer and pay that premium?

Accepted Answer

No later than the 31st day after the date of birth

Answer

No later than the 10th day after the date of birth

Answer

No later than the 15th day after the date of birth

Answer

No later than the 60th day after the date of birth

Question 3

For purposes of the Texas chemical dependency coverage mandate, chemical dependency includes abuse of, psychological or physical dependence on, or addiction to which of the following?

Accepted Answer

Alcohol or a controlled substance

Answer

Illegal controlled substances only

Answer

Prescription medications only

Answer

Tobacco products only

Question 4

A baby covered under her mother's Texas accident and health policy is born at 28 weeks with a medically diagnosed congenital heart defect and spends six weeks in neonatal intensive care. How does the newborn mandate apply?

Accepted Answer

Care and treatment of the injury and illness are covered, including the congenital defect and prematurity

Answer

Only routine well-baby nursery charges are covered; the NICU stay is excluded as a pre-existing condition

Answer

Coverage applies only after the infant is separately underwritten and accepted

Answer

Coverage begins only once the infant is medically stable and ready for discharge

Question 5

Besides a newborn biological child, which of the following must the Texas newborn coverage provision also reach?

Accepted Answer

An adopted child, and a child for whom the insured is a party to a suit seeking adoption

Answer

Only a child legally adopted at least one year before the policy was issued

Answer

Any minor residing in the insured's household, regardless of legal relationship

Answer

Only a stepchild whose natural parent is the named insured

Question 6

Under Texas law, on what terms must a covered group health benefit plan provide the chemical dependency benefit?

Accepted Answer

On the same basis as coverage for physical illness under the plan

Answer

At the insurer's discretion, with any limits it chooses to file

Answer

Only as an optional rider the employer may purchase separately

Answer

Only for the portion of treatment delivered on an outpatient basis

Question 7

A father's Texas policy requires an additional premium to continue coverage for a new dependent. His son is born on March 1, and the father does not notify the insurer or pay the additional premium until April 20. Which statement best describes the situation?

Accepted Answer

The child was covered from the moment of birth, but because the notice and premium deadline passed, the insurer may end the automatic coverage

Answer

The child was never covered, because coverage could not attach until the premium was paid

Answer

The insurer must continue the coverage indefinitely, because the notice requirement is unenforceable

Answer

The child remains covered because the insured paid within 60 days of birth

Question 8

A group plan sponsor asks how chemical dependency treatment must be delivered for the mandated benefit to apply in Texas. The best answer is that treatment must be provided:

Accepted Answer

Through appropriately licensed or approved facilities and providers, such as a chemical dependency treatment center meeting state standards

Answer

Only in a general acute care hospital's inpatient psychiatric unit

Answer

By any provider the covered person selects, licensed or not, so long as costs are reasonable

Answer

Only by a physician who is board certified in addiction medicine

Question 9

A Texas individual accident and health policy provides coverage for the insured's family members. When does coverage for the insured's newborn child begin?

Accepted Answer

From the moment of birth

Answer

On the 31st day after birth, once notice is given

Answer

On the date the child is discharged from the hospital in good health

Answer

On the policy's next anniversary date following the birth

Question 10

Continued coverage of an insured's newborn under a Texas accident and health policy depends on payment of an additional premium. By when may the policy require the insured to notify the insurer of the birth and pay that premium?

Accepted Answer

No later than the 31st day after the date of birth

Answer

No later than the 10th day after the date of birth

Answer

No later than the 15th day after the date of birth

Answer

No later than the 20th day after the date of birth

Question 11

For purposes of the Texas mandated chemical dependency benefit, chemical dependency includes abuse of, psychological or physical dependence on, or addiction to:

Accepted Answer

Alcohol or a controlled substance

Answer

Illegal drugs only

Answer

Prescription medications only

Answer

Tobacco products only

Question 12

A baby covered from birth under a Texas accident and health policy is born ten weeks premature and is diagnosed with a congenital heart defect. How does the newborn coverage mandate apply?

Accepted Answer

Care and treatment of injury and illness, including medically diagnosed congenital defects, birth abnormalities, and prematurity, must be covered

Answer

Only routine well-baby nursery care is covered; the defect and prematurity are excludable

Answer

The conditions are covered only if the infant survives past the 31st day

Answer

The conditions are covered only if the mother purchased a maternity rider

Question 13

Beyond a newborn biological child, the Texas newborn coverage requirement in Chapter 1201 also reaches:

Accepted Answer

An adopted child, and a child for whom the insured is a party to a suit seeking adoption

Answer

Any minor residing in the insured's household regardless of legal relationship

Answer

A grandchild of the insured whose parents are uninsured

Answer

A foster child, but only after the placement becomes permanent

Question 14

Under the Texas chemical dependency mandate, the required benefit must be provided:

Accepted Answer

On the same basis as coverage for physical illness under the plan

Answer

Subject to a separate lifetime maximum of one treatment episode

Answer

Only as an optional rider the employer may decline

Answer

Only after the covered person exhausts all outpatient benefits

Question 15

A child is born on March 1 to an insured whose Texas policy requires an additional premium to continue coverage of a dependent child. The insured never notifies the insurer and never pays the additional premium. Which statement best describes the result?

Accepted Answer

The child was covered from the moment of birth, but the insurer may end that automatic coverage because notice and premium were not provided within the statutory window

Answer

The child was never covered, because coverage attaches only upon notice and premium payment

Answer

The child remains covered indefinitely, because the notice requirement is unenforceable

Answer

The child's coverage retroactively voids the entire policy for material misrepresentation

Question 16

A group health benefit plan in Texas pays for chemical dependency treatment. Which condition on the delivery of that treatment is consistent with the Texas mandate?

Accepted Answer

Treatment must be provided through appropriately licensed or approved facilities and providers

Answer

Treatment must be delivered only in an acute-care general hospital

Answer

Treatment must be self-directed through a peer support group before any benefits are payable

Answer

Treatment must be provided out of state to qualify for the mandated benefit

Question 17

A Texas individual accident and health policy provides coverage for the insured's family members. The insured's baby is born prematurely and is immediately admitted to a neonatal intensive care unit, where she remains for six weeks. Under Chapter 1201, when did coverage for the newborn attach?

Accepted Answer

From the moment of birth

Answer

On the date the infant is discharged from the hospital in stable condition

Answer

On the 31st day after the date of birth

Answer

On the date the insurer receives any additional premium for the child

Question 18

Continued coverage of a newborn under a Texas accident and health policy will require payment of an additional premium. By when may the policy require the insured to notify the insurer of the birth and pay that premium?

Accepted Answer

No later than the 31st day after the date of birth

Answer

No later than the 10th day after the date of birth

Answer

No later than the 15th day after the date of birth

Answer

No later than 30 days after the infant is discharged from the hospital

Question 19

For purposes of the Texas mandated chemical dependency benefit, chemical dependency is defined to include which of the following?

Accepted Answer

The abuse of, psychological or physical dependence on, or addiction to alcohol or a controlled substance

Answer

Dependence on illegal controlled substances only, excluding alcohol

Answer

Only conditions severe enough to require inpatient hospitalization

Answer

Any compulsive behavior a treating physician labels an addiction, whether or not a substance is involved

Question 20

Beyond routine well-baby care, what must a Texas accident and health policy's newborn coverage include?

Accepted Answer

Care and treatment of the newborn's injury and illness, including medically diagnosed congenital defects, birth abnormalities, and prematurity

Answer

Only care for illnesses that first appear after the infant leaves the hospital

Answer

Care for injury and acute illness, but not conditions present at birth

Answer

Care for prematurity only if the infant weighs less than a stated minimum at birth

Question 21

In addition to a newborn biological child, the Texas newborn coverage provisions of Chapter 1201 also reach which child or children?

Accepted Answer

An adopted child, and a child for whom the insured is a party to a suit seeking adoption

Answer

Only a child legally adopted before the child's first birthday

Answer

Only a stepchild residing in the insured's household

Answer

Only a child placed with the insured as a foster child by the state

Question 22

A Texas group health benefit plan pays for treatment of chemical dependency but imposes a shorter benefit period, a higher deductible, and a lower lifetime maximum than it applies to physical illness. What is the problem with this design?

Accepted Answer

The mandated chemical dependency benefit must be provided on the same basis as coverage for physical illness

Answer

Nothing — chemical dependency benefits may be structured however the plan sponsor chooses

Answer

Nothing, as long as the plan discloses the differences in the certificate of coverage

Answer

Chemical dependency treatment must instead be covered more generously than physical illness

Question 23

A child is born on March 3 under a Texas policy where continued coverage of the newborn requires an additional premium. The insured never notifies the insurer and never pays the premium. Which statement best describes the result?

Accepted Answer

Coverage existed from the moment of birth, but the insurer may end the automatic coverage because notice and the additional premium were not provided by the 31st day after birth

Answer

Coverage never attached, because notice and premium were conditions precedent to any coverage of the child

Answer

Coverage must continue indefinitely, because a newborn's coverage cannot be terminated for nonpayment

Answer

Coverage attached on the 31st day after birth and continues until the insurer sends a cancellation notice

Question 24

Under the Texas chemical dependency mandate, how must the required care and treatment be delivered for the benefit to apply?

Accepted Answer

Through appropriately licensed or approved facilities and providers, such as a chemical dependency treatment center meeting state standards

Answer

Only in an acute-care general hospital with an inpatient psychiatric unit

Answer

Only by a physician who is board certified in addiction medicine

Answer

By any provider the covered person selects, licensed or not, so long as treatment is medically necessary

Question 25

An individual accident and health policy issued in Texas provides coverage for the insured's family members. Under Texas Insurance Code Chapter 1201, at what point must coverage for the insured's newborn child begin?

Accepted Answer

From the moment of birth

Answer

On the date the insurer approves the child's enrollment application

Answer

On the 31st day after the date of birth

Answer

On the date the newborn is discharged from the hospital in good health

Question 26

A Texas policy requires an additional premium to continue coverage for a newborn child. By what deadline may the policy require the insured to notify the insurer of the birth and pay that premium?

Accepted Answer

No later than the 31st day after the date of birth

Answer

No later than the 10th day after the date of birth

Answer

No later than the 21st day after the date of birth

Answer

No later than the 60th day after the date of birth

Question 27

Beyond routine well-baby care, what must newborn coverage under a Texas accident and health policy include?

Accepted Answer

Injury and illness, including medically diagnosed congenital defects, birth abnormalities, and prematurity

Answer

Only injury and illness arising after the newborn's discharge from the hospital

Answer

Injury and illness, but expressly excluding conditions present at birth

Answer

Only conditions that develop during the first 31 days of life

Question 28

Under Texas law, the mandated benefit for chemical dependency treatment applies to dependency involving which of the following?

Accepted Answer

Alcohol or a controlled substance

Answer

Illegal controlled substances only

Answer

Tobacco products only

Answer

Prescription medications only, when obtained without a prescription

Question 29

A Texas group health benefit plan covers chemical dependency treatment but imposes visit limits and cost sharing far more restrictive than those it applies to any physical illness. What principle does this most directly violate?

Accepted Answer

The requirement that the benefit be provided on the same basis as coverage for physical illness

Answer

The requirement that treatment be delivered only by out-of-network providers

Answer

The requirement that coverage begin from the moment of diagnosis

Answer

The requirement that the employer obtain written waivers from enrollees

Question 30

An insured is a party to a suit seeking to adopt an infant, and the child is placed in the insured's home before the adoption is final. How does Chapter 1201 treat that child under a family policy?

Accepted Answer

The statute's newborn child protections reach an adopted child and a child for whom the insured is a party to a suit seeking adoption

Answer

The child has no coverage rights until the adoption decree is entered

Answer

Coverage is available only if the child is under 31 days old at placement

Answer

The child may be covered only under a separate individual policy purchased for the child

Question 31

A baby is born ten weeks premature and spends five weeks in neonatal intensive care. The parents notify the insurer of the birth and pay the required additional premium on the 40th day after birth. Which statement best describes the coverage outcome?

Accepted Answer

Coverage attached from the moment of birth and included the prematurity care, but because notice and premium came after the 31st day the insurer may end the automatic continued coverage

Answer

The NICU stay was never covered because prematurity is excluded from newborn coverage

Answer

Coverage never attached because notice is a condition of the coverage beginning

Answer

The insurer must continue the child's coverage because the 31-day deadline applies only to biological children

Question 32

An employer group client asks its producer whether it can simply drop chemical dependency treatment from its Texas group health benefit plan to save money, and also asks who may render the covered treatment. What is the producer's most accurate response?

Accepted Answer

The benefit is mandated for covered plans and is not something the employer buys out of at will, and treatment must be delivered through appropriately licensed or approved facilities and providers

Answer

The benefit is optional, and treatment may be rendered by any provider the employer designates

Answer

The benefit is mandated, but only for controlled substance dependency and only in inpatient settings

Answer

The benefit is optional if the plan instead increases its physical illness benefits proportionally

Question 33

Under Texas Insurance Code Chapter 1201, when an individual accident and health policy provides coverage for members of the insured's family, when must coverage for a newborn child of the insured begin?

Accepted Answer

From the moment of the child's birth

Answer

On the date the insurer approves the child's enrollment application

Answer

On the date the child is discharged from the hospital in good health

Answer

On the 31st day after the date of birth

Question 34

A policy conditions continued coverage of a newborn on payment of an additional premium. Under Chapter 1201, what is the latest the policy may require the insured to notify the insurer of the birth and pay that premium?

Accepted Answer

No later than the 31st day after the date of birth

Answer

No later than the 10th day after the date of birth

Answer

No later than the 60th day after the date of birth

Answer

No later than the next policy anniversary date

Question 35

An infant covered under a Texas individual accident and health policy is born nine weeks premature with a medically diagnosed congenital heart defect and spends five weeks in neonatal intensive care. Under Chapter 1201, how must the required newborn coverage treat this care?

Accepted Answer

The care must be covered, because required newborn coverage includes injury and illness, including medically diagnosed congenital defects, birth abnormalities, and prematurity

Answer

Only routine well-baby nursery charges must be covered; the NICU stay is excludable as a pre-existing condition

Answer

Coverage applies only after the newborn is separately enrolled and individually underwritten

Answer

Congenital defects must be covered, but prematurity-related care may be excluded

Question 36

For purposes of the Texas mandated chemical dependency benefit, chemical dependency is defined to reach abuse of, psychological or physical dependence on, or addiction to which of the following?

Accepted Answer

Alcohol or a controlled substance

Answer

Illegal controlled substances only

Answer

Prescription medications only

Answer

Tobacco products and caffeine only

Question 37

A Texas group health benefit plan covers chemical dependency treatment but imposes a separate, far more restrictive day limit and a higher coinsurance percentage than it applies to any physical illness. Why is this design a problem under Title 8?

Accepted Answer

Title 8 requires the chemical dependency benefit to be provided on the same basis as coverage for physical illness under the plan

Answer

Title 8 prohibits any cost sharing at all for chemical dependency treatment

Answer

Title 8 requires that chemical dependency benefits be richer than physical illness benefits

Answer

Title 8 permits the plan to exclude chemical dependency treatment entirely, so partial coverage is the violation

Question 38

Beyond a newborn biological child, Chapter 1201's required coverage provision also reaches which of the following?

Accepted Answer

An adopted child, and a child for whom the insured is a party to a suit seeking adoption

Answer

Only a stepchild who resides in the insured's household

Answer

Only a child placed by a licensed agency after the adoption is final and a court order is issued

Answer

Any minor relative for whom the insured provides more than half of financial support

Question 39

A newborn is delivered on March 3. The policy requires an additional premium to continue coverage on the child, and the insured neither notifies the carrier nor pays the premium until April 20. Which statement best describes the result?

Accepted Answer

The child was covered from the moment of birth, but because the notice and premium deadline was missed the insurer may end the automatic coverage

Answer

The child was never covered, because coverage could not attach before the premium was paid

Answer

The insurer must continue the coverage indefinitely, because notice and premium requirements are unenforceable

Answer

Coverage began on the 31st day after birth and continues because payment was made within 60 days

Question 40

An employer's Texas group health benefit plan wants to satisfy the mandated chemical dependency benefit by paying only for treatment delivered at an unlicensed residential retreat run by lay counselors. What is the flaw in this approach?

Accepted Answer

The mandated treatment must be delivered through appropriately licensed or approved facilities and providers

Answer

The mandate applies only to inpatient hospital care, so residential settings never qualify

Answer

The plan may choose any provider it wishes because the mandate addresses only the dollar amount payable

Answer

The mandate applies only to plans that also cover mental illness, so the plan is exempt

Under Texas law, when an individual accident and health policy covers the insured's family members, when does coverage for a newborn child of the insured begin?

If continued coverage of a newborn depends on payment of an additional premium, by when may the policy require the insured to notify the insurer and pay that premium?

For purposes of the Texas chemical dependency coverage mandate, chemical dependency includes abuse of, psychological or physical dependence on, or addiction to which of the following?

A baby covered under her mother's Texas accident and health policy is born at 28 weeks with a medically diagnosed congenital heart defect and spends six weeks in neonatal intensive care. How does the newborn mandate apply?

Besides a newborn biological child, which of the following must the Texas newborn coverage provision also reach?

Under Texas law, on what terms must a covered group health benefit plan provide the chemical dependency benefit?

A father's Texas policy requires an additional premium to continue coverage for a new dependent. His son is born on March 1, and the father does not notify the insurer or pay the additional premium until April 20. Which statement best describes the situation?

A group plan sponsor asks how chemical dependency treatment must be delivered for the mandated benefit to apply in Texas. The best answer is that treatment must be provided:

A Texas individual accident and health policy provides coverage for the insured's family members. When does coverage for the insured's newborn child begin?

Continued coverage of an insured's newborn under a Texas accident and health policy depends on payment of an additional premium. By when may the policy require the insured to notify the insurer of the birth and pay that premium?

For purposes of the Texas mandated chemical dependency benefit, chemical dependency includes abuse of, psychological or physical dependence on, or addiction to:

A baby covered from birth under a Texas accident and health policy is born ten weeks premature and is diagnosed with a congenital heart defect. How does the newborn coverage mandate apply?

Beyond a newborn biological child, the Texas newborn coverage requirement in Chapter 1201 also reaches:

Under the Texas chemical dependency mandate, the required benefit must be provided:

A child is born on March 1 to an insured whose Texas policy requires an additional premium to continue coverage of a dependent child. The insured never notifies the insurer and never pays the additional premium. Which statement best describes the result?

A group health benefit plan in Texas pays for chemical dependency treatment. Which condition on the delivery of that treatment is consistent with the Texas mandate?

A Texas individual accident and health policy provides coverage for the insured's family members. The insured's baby is born prematurely and is immediately admitted to a neonatal intensive care unit, where she remains for six weeks. Under Chapter 1201, when did coverage for the newborn attach?

Continued coverage of a newborn under a Texas accident and health policy will require payment of an additional premium. By when may the policy require the insured to notify the insurer of the birth and pay that premium?

For purposes of the Texas mandated chemical dependency benefit, chemical dependency is defined to include which of the following?

Beyond routine well-baby care, what must a Texas accident and health policy's newborn coverage include?

In addition to a newborn biological child, the Texas newborn coverage provisions of Chapter 1201 also reach which child or children?

A Texas group health benefit plan pays for treatment of chemical dependency but imposes a shorter benefit period, a higher deductible, and a lower lifetime maximum than it applies to physical illness. What is the problem with this design?

A child is born on March 3 under a Texas policy where continued coverage of the newborn requires an additional premium. The insured never notifies the insurer and never pays the premium. Which statement best describes the result?

Under the Texas chemical dependency mandate, how must the required care and treatment be delivered for the benefit to apply?

An individual accident and health policy issued in Texas provides coverage for the insured's family members. Under Texas Insurance Code Chapter 1201, at what point must coverage for the insured's newborn child begin?

A Texas policy requires an additional premium to continue coverage for a newborn child. By what deadline may the policy require the insured to notify the insurer of the birth and pay that premium?

Beyond routine well-baby care, what must newborn coverage under a Texas accident and health policy include?

Under Texas law, the mandated benefit for chemical dependency treatment applies to dependency involving which of the following?

A Texas group health benefit plan covers chemical dependency treatment but imposes visit limits and cost sharing far more restrictive than those it applies to any physical illness. What principle does this most directly violate?

An insured is a party to a suit seeking to adopt an infant, and the child is placed in the insured's home before the adoption is final. How does Chapter 1201 treat that child under a family policy?

A baby is born ten weeks premature and spends five weeks in neonatal intensive care. The parents notify the insurer of the birth and pay the required additional premium on the 40th day after birth. Which statement best describes the coverage outcome?

An employer group client asks its producer whether it can simply drop chemical dependency treatment from its Texas group health benefit plan to save money, and also asks who may render the covered treatment. What is the producer's most accurate response?

Under Texas Insurance Code Chapter 1201, when an individual accident and health policy provides coverage for members of the insured's family, when must coverage for a newborn child of the insured begin?

A policy conditions continued coverage of a newborn on payment of an additional premium. Under Chapter 1201, what is the latest the policy may require the insured to notify the insurer of the birth and pay that premium?

An infant covered under a Texas individual accident and health policy is born nine weeks premature with a medically diagnosed congenital heart defect and spends five weeks in neonatal intensive care. Under Chapter 1201, how must the required newborn coverage treat this care?

For purposes of the Texas mandated chemical dependency benefit, chemical dependency is defined to reach abuse of, psychological or physical dependence on, or addiction to which of the following?

A Texas group health benefit plan covers chemical dependency treatment but imposes a separate, far more restrictive day limit and a higher coinsurance percentage than it applies to any physical illness. Why is this design a problem under Title 8?

Beyond a newborn biological child, Chapter 1201's required coverage provision also reaches which of the following?

A newborn is delivered on March 3. The policy requires an additional premium to continue coverage on the child, and the insured neither notifies the carrier nor pays the premium until April 20. Which statement best describes the result?

An employer's Texas group health benefit plan wants to satisfy the mandated chemical dependency benefit by paying only for treatment delivered at an unlicensed residential retreat run by lay counselors. What is the flaw in this approach?

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