Required policy provisions: newborn and chemical-dependency coverage
Question 1 of 40
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?
On the date the insurer approves an application for the child
On the 31st day after the date of birth
On the date the child is discharged from the hospital in good health
From the moment of birth
Question 2 of 40
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?
No later than the 10th day after the date of birth
No later than the 15th day after the date of birth
No later than the 31st day after the date of birth
No later than the 60th day after the date of birth
Question 3 of 40
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?
Illegal controlled substances only
Prescription medications only
Tobacco products only
Alcohol or a controlled substance
Question 4 of 40
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?
Only routine well-baby nursery charges are covered; the NICU stay is excluded as a pre-existing condition
Care and treatment of the injury and illness are covered, including the congenital defect and prematurity
Coverage applies only after the infant is separately underwritten and accepted
Coverage begins only once the infant is medically stable and ready for discharge
Question 5 of 40
Besides a newborn biological child, which of the following must the Texas newborn coverage provision also reach?
An adopted child, and a child for whom the insured is a party to a suit seeking adoption
Only a child legally adopted at least one year before the policy was issued
Any minor residing in the insured's household, regardless of legal relationship
Only a stepchild whose natural parent is the named insured
Question 6 of 40
Under Texas law, on what terms must a covered group health benefit plan provide the chemical dependency benefit?
At the insurer's discretion, with any limits it chooses to file
Only as an optional rider the employer may purchase separately
On the same basis as coverage for physical illness under the plan
Only for the portion of treatment delivered on an outpatient basis
Question 7 of 40
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?
The child was covered from the moment of birth, but because the notice and premium deadline passed, the insurer may end the automatic coverage
The child was never covered, because coverage could not attach until the premium was paid
The insurer must continue the coverage indefinitely, because the notice requirement is unenforceable
The child remains covered because the insured paid within 60 days of birth
Question 8 of 40
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:
Only in a general acute care hospital's inpatient psychiatric unit
Through appropriately licensed or approved facilities and providers, such as a chemical dependency treatment center meeting state standards
By any provider the covered person selects, licensed or not, so long as costs are reasonable
Only by a physician who is board certified in addiction medicine
Question 9 of 40
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?
From the moment of birth
On the 31st day after birth, once notice is given
On the date the child is discharged from the hospital in good health
On the policy's next anniversary date following the birth
Question 10 of 40
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?
No later than the 10th day after the date of birth
No later than the 15th day after the date of birth
No later than the 20th day after the date of birth
No later than the 31st day after the date of birth
Question 11 of 40
For purposes of the Texas mandated chemical dependency benefit, chemical dependency includes abuse of, psychological or physical dependence on, or addiction to:
Illegal drugs only
Prescription medications only
Tobacco products only
Alcohol or a controlled substance
Question 12 of 40
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?
Only routine well-baby nursery care is covered; the defect and prematurity are excludable
Care and treatment of injury and illness, including medically diagnosed congenital defects, birth abnormalities, and prematurity, must be covered
The conditions are covered only if the infant survives past the 31st day
The conditions are covered only if the mother purchased a maternity rider
Question 13 of 40
Beyond a newborn biological child, the Texas newborn coverage requirement in Chapter 1201 also reaches:
Any minor residing in the insured's household regardless of legal relationship
A grandchild of the insured whose parents are uninsured
An adopted child, and a child for whom the insured is a party to a suit seeking adoption
A foster child, but only after the placement becomes permanent
Question 14 of 40
Under the Texas chemical dependency mandate, the required benefit must be provided:
On the same basis as coverage for physical illness under the plan
Subject to a separate lifetime maximum of one treatment episode
Only as an optional rider the employer may decline
Only after the covered person exhausts all outpatient benefits
Question 15 of 40
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?
The child was never covered, because coverage attaches only upon notice and premium payment
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
The child remains covered indefinitely, because the notice requirement is unenforceable
The child's coverage retroactively voids the entire policy for material misrepresentation
Question 16 of 40
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?
Treatment must be delivered only in an acute-care general hospital
Treatment must be self-directed through a peer support group before any benefits are payable
Treatment must be provided through appropriately licensed or approved facilities and providers
Treatment must be provided out of state to qualify for the mandated benefit
Question 17 of 40
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?
From the moment of birth
On the date the infant is discharged from the hospital in stable condition
On the 31st day after the date of birth
On the date the insurer receives any additional premium for the child
Question 18 of 40
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?
No later than the 10th day after the date of birth
No later than the 15th day after the date of birth
No later than 30 days after the infant is discharged from the hospital
No later than the 31st day after the date of birth
Question 19 of 40
For purposes of the Texas mandated chemical dependency benefit, chemical dependency is defined to include which of the following?
The abuse of, psychological or physical dependence on, or addiction to alcohol or a controlled substance
Dependence on illegal controlled substances only, excluding alcohol
Only conditions severe enough to require inpatient hospitalization
Any compulsive behavior a treating physician labels an addiction, whether or not a substance is involved
Question 20 of 40
Beyond routine well-baby care, what must a Texas accident and health policy's newborn coverage include?
Only care for illnesses that first appear after the infant leaves the hospital
Care and treatment of the newborn's injury and illness, including medically diagnosed congenital defects, birth abnormalities, and prematurity
Care for injury and acute illness, but not conditions present at birth
Care for prematurity only if the infant weighs less than a stated minimum at birth
Question 21 of 40
In addition to a newborn biological child, the Texas newborn coverage provisions of Chapter 1201 also reach which child or children?
Only a child legally adopted before the child's first birthday
Only a stepchild residing in the insured's household
Only a child placed with the insured as a foster child by the state
An adopted child, and a child for whom the insured is a party to a suit seeking adoption
Question 22 of 40
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?
Nothing — chemical dependency benefits may be structured however the plan sponsor chooses
Nothing, as long as the plan discloses the differences in the certificate of coverage
The mandated chemical dependency benefit must be provided on the same basis as coverage for physical illness
Chemical dependency treatment must instead be covered more generously than physical illness
Question 23 of 40
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?
Coverage never attached, because notice and premium were conditions precedent to any coverage of the child
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
Coverage must continue indefinitely, because a newborn's coverage cannot be terminated for nonpayment
Coverage attached on the 31st day after birth and continues until the insurer sends a cancellation notice
Question 24 of 40
Under the Texas chemical dependency mandate, how must the required care and treatment be delivered for the benefit to apply?
Only in an acute-care general hospital with an inpatient psychiatric unit
Only by a physician who is board certified in addiction medicine
Through appropriately licensed or approved facilities and providers, such as a chemical dependency treatment center meeting state standards
By any provider the covered person selects, licensed or not, so long as treatment is medically necessary
Question 25 of 40
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?
From the moment of birth
On the date the insurer approves the child's enrollment application
On the 31st day after the date of birth
On the date the newborn is discharged from the hospital in good health
Question 26 of 40
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?
No later than the 10th day after the date of birth
No later than the 21st day after the date of birth
No later than the 31st day after the date of birth
No later than the 60th day after the date of birth
Question 27 of 40
Beyond routine well-baby care, what must newborn coverage under a Texas accident and health policy include?
Only injury and illness arising after the newborn's discharge from the hospital
Injury and illness, including medically diagnosed congenital defects, birth abnormalities, and prematurity
Injury and illness, but expressly excluding conditions present at birth
Only conditions that develop during the first 31 days of life
Question 28 of 40
Under Texas law, the mandated benefit for chemical dependency treatment applies to dependency involving which of the following?
Alcohol or a controlled substance
Illegal controlled substances only
Tobacco products only
Prescription medications only, when obtained without a prescription
Question 29 of 40
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?
The requirement that treatment be delivered only by out-of-network providers
The requirement that coverage begin from the moment of diagnosis
The requirement that the benefit be provided on the same basis as coverage for physical illness
The requirement that the employer obtain written waivers from enrollees
Question 30 of 40
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?
The child has no coverage rights until the adoption decree is entered
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
Coverage is available only if the child is under 31 days old at placement
The child may be covered only under a separate individual policy purchased for the child
Question 31 of 40
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?
The NICU stay was never covered because prematurity is excluded from newborn coverage
Coverage never attached because notice is a condition of the coverage beginning
The insurer must continue the child's coverage because the 31-day deadline applies only to biological children
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
Question 32 of 40
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?
The benefit is optional, and treatment may be rendered by any provider the employer designates
The benefit is mandated, but only for controlled substance dependency and only in inpatient settings
The benefit is optional if the plan instead increases its physical illness benefits proportionally
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
Question 33 of 40
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?
On the date the insurer approves the child's enrollment application
On the date the child is discharged from the hospital in good health
From the moment of the child's birth
On the 31st day after the date of birth
Question 34 of 40
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?
No later than the 31st day after the date of birth
No later than the 10th day after the date of birth
No later than the 60th day after the date of birth
No later than the next policy anniversary date
Question 35 of 40
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?
Only routine well-baby nursery charges must be covered; the NICU stay is excludable as a pre-existing condition
Coverage applies only after the newborn is separately enrolled and individually underwritten
Congenital defects must be covered, but prematurity-related care may be excluded
The care must be covered, because required newborn coverage includes injury and illness, including medically diagnosed congenital defects, birth abnormalities, and prematurity
Question 36 of 40
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?
Alcohol or a controlled substance
Illegal controlled substances only
Prescription medications only
Tobacco products and caffeine only
Question 37 of 40
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?
Title 8 prohibits any cost sharing at all for chemical dependency treatment
Title 8 requires that chemical dependency benefits be richer than physical illness benefits
Title 8 permits the plan to exclude chemical dependency treatment entirely, so partial coverage is the violation
Title 8 requires the chemical dependency benefit to be provided on the same basis as coverage for physical illness under the plan
Question 38 of 40
Beyond a newborn biological child, Chapter 1201's required coverage provision also reaches which of the following?
Only a stepchild who resides in the insured's household
An adopted child, and a child for whom the insured is a party to a suit seeking adoption
Only a child placed by a licensed agency after the adoption is final and a court order is issued
Any minor relative for whom the insured provides more than half of financial support
Question 39 of 40
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?
The child was never covered, because coverage could not attach before the premium was paid
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
The insurer must continue the coverage indefinitely, because notice and premium requirements are unenforceable
Coverage began on the 31st day after birth and continues because payment was made within 60 days
Question 40 of 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?
The mandate applies only to inpatient hospital care, so residential settings never qualify
The plan may choose any provider it wishes because the mandate addresses only the dollar amount payable
The mandated treatment must be delivered through appropriately licensed or approved facilities and providers
The mandate applies only to plans that also cover mental illness, so the plan is exempt