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Alabama insurance law pertinent to
accident and health disability Questions
with Detailed Verified Answers (100%
Correct Answers) /Already Graded A+
A. General Provisions and Certain Required Coverages
Ans: Mandatory and optional accident and health insurance policy provisions have already
been covered in the Uniform Individual Health Policy Provisions chapter. Make sure you review
that section before your exam.
1. Inpatient Care for Mothers and Newborns
Ans: All health benefit plans that provide maternity coverage must also provide coverage for
the following:
All inpatient care determined medically necessary for a mother and her newborn child by the
woman’s prenatal care physician, obstetrician-gynecologist, certified nurse midwife, or the
child’s attending physician;
Benefits for any hospital stay of at least 48 hours in connection with childbirth following a
normal vaginal delivery; and
Benefits for any hospital stay of at least 96 hours in connection with childbirth following a
cesarean section.
Health benefit plan
Ans: A health benefit plan may not terminate the services or otherwise penalize an attending
physician, certified nurse midwife, or other health care provider for ordering medical care
consistent with the requirements.
Also, a plan may not provide any financial incentive or disincentive, or grant or deny special
advantages to a person to encourage or cause the early discharge of a patient from
postpartum care (this does not include capitation or global fee arrangements).
2. Obstetricians and Gynecologists as Primary Care Physicians
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Ans: All health benefit plans issued or delivered in Alabama must allow obstetricians and
gynecologists as primary care physicians. The obstetrician or gynecologist may decline to
accept primary care physician status at his or her option.
Health benefit plans may not require a referral from another primary care physician as a
condition to coverage for the services of a participating obstetrician or gynecologist.
3. Breast Cancer Screening
Ans: All health benefit plans that provide coverage for mastectomies must also provide
coverage for screening mammography at least every 2 years for women age 40 to 49
(inclusive) and at least once every year for women age 50 and over. More frequent
mammograms must be covered if based on the recommendation of the woman’s physician.
4. Mental Illness Coverage
Ans: All group health benefit plans must offer to provide, at a minimum, inpatient, day
treatment, and outpatient services as additional benefits for persons suffering from a mental
or nervous condition. All group health benefit plans must at least offer additional benefits for
those receiving treatment for any of the following when diagnosed by an appropriately
licensed provider:
Schizophrenia, schizophrenia form disorder, schizo affective disorder
Bipolar disorder
Panic disorder
Obsessive-compulsive disorder
Major depressive disorder
Anxiety and mood disorders
Any condition or disorder that involves mental illness.
The benefits offered for treatment and diagnosis of mental illness must be under terms and
conditions no less extensive than those for benefits provided for physical illnesses.
5. Payments to Mental Patients
Ans: Health insurance policies issued for delivery that provide coverage for psychiatric
treatment or mental illness cannot exclude hospitalization benefits for mental patients in tax-
supported institutions.
6. Prescription Drug Coverage
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Ans: No health insurance policy or employee benefit plan that provides coverage for
pharmaceutical services may prevent any beneficiary from selecting the pharmacy or
pharmacist of his or her choice to provide pharmaceutical services as long as the pharmacy or
pharmacist is licensed to furnish pharmaceutical services in Alabama. No pharmacy or
pharmacist may be denied from the right to participate as a contracting provider as long as
the pharmacy or pharmacist is licensed to furnish the pharmaceutical services offered by the
policy or plan.
7. Alcoholism Treatment in Group Plans
Ans: All group, blanket, franchise, association health insurance policies, and health
maintenance organization plans issued in Alabama must provide, at the option of the
policyholder or sponsor, coverage for the treatment of alcoholism when prescribed by a
licensed doctor of medicine. The benefits offered must include inpatient or residential
treatment at a state-licensed hospital or a licensed or certified short-term residential
alcoholism treatment facility or detoxification facility. Benefits must also include outpatient
treatment by a licensed doctor of medicine or a licensed or certified alcoholism treatment
facility.
Benefits must provide for a minimum of 30 days of inpatient treatment or its equivalent per
calendar year. Equivalency must be determined using a formula that equates 2 days of
treatment in a short term residential alcoholism facility or 3 sessions of outpatient treatment by
a licensed doctor of medicine or alcoholism treatment facility to 1 day of inpatient treatment.
8. Military Suspense Provision
Ans: If a policy contains a military service exclusion or a provision suspending coverage
during military service, or if the premiums are either reduced or refunded for the period of
military service, that fact must be clearly stated in the policy.
B. HMOs and Alabama Health Insurance Plan
1. HMOs
Ans: You have already studied the basic principles that govern Health Maintenance
Organizations and the policies issued by them. Make sure you review that information before
your exam. Below are some additional requirements for HMO policies issued in this state.
Evidence of Coverage
