Key Takeaways
- Arizona requires a 10-day free look period for individual health insurance policies (20 days for seniors)
- Arizona follows the federal Affordable Care Act requirements for essential health benefits
- Pre-existing condition exclusions are prohibited in Arizona individual and small group markets under the ACA
- Arizona does NOT have a state-run health insurance exchange; it uses the federal HealthCare.gov marketplace
- Health insurance policies must include required provisions for grace periods, claims, and renewability
Arizona Health Insurance Policy Requirements
Arizona has health insurance regulations that work alongside federal Affordable Care Act (ACA) requirements. Understanding these state-specific rules is essential for the licensing exam.
Regulatory Structure
Arizona health coverage is regulated by:
| Entity | Role |
|---|---|
| DIFI | Regulates insurance companies and producers |
| Federal Government | ACA requirements apply |
| HealthCare.gov | Federal marketplace for ACA plans |
Federal Marketplace
Arizona does NOT operate its own health insurance exchange:
- Uses HealthCare.gov (federal marketplace)
- Arizona residents enroll through federal platform
- Open enrollment and special enrollment apply
- Premium tax credits available based on income
Free Look Period
Arizona provides a 10-day free look period for individual health insurance:
| Policyholder Age | Free Look Period |
|---|---|
| Under 65 | 10 days |
| Age 65 and older | 20 days |
- Policyholder can return for full premium refund
- Begins when policy is delivered
- Applies to individual health policies
Exam Tip: Arizona extends the free look to 20 days for persons 65 and older for ALL insurance products, including health insurance.
Essential Health Benefits
Arizona follows federal ACA requirements for essential health benefits in individual and small group plans:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
Pre-Existing Condition Protections
Arizona follows ACA prohibitions on pre-existing condition exclusions:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual (ACA) | Prohibited |
| Small Group | Prohibited |
| Large Group | Limited restrictions |
| Short-term Plans | May apply (different rules) |
Short-Term Health Insurance
Arizona allows short-term health insurance:
- Duration up to 364 days
- May renew for up to 36 months total
- NOT required to cover essential health benefits
- May exclude pre-existing conditions
- Must include clear disclosure that it's not ACA-compliant
Required Policy Provisions
Arizona health insurance policies must include:
Mandatory Provisions
| Provision | Requirement |
|---|---|
| Grace Period | 31 days for premium payment |
| Reinstatement | Within 3 years upon payment and evidence of insurability |
| Claims Notice | Written notice within 20 days of loss |
| Claims Forms | Insurer must furnish within 15 days of request |
| Proof of Loss | Must be filed within 90 days of loss |
| Payment of Claims | Benefits payable immediately upon receipt of proof |
| Legal Actions | Not before 60 days or after 3 years |
Prohibited Provisions
- Provisions limiting claims to less than 3 years after start of disability
- Provisions reducing benefits for pre-existing conditions beyond allowed limits
- Provisions automatically canceling coverage without cause
Guaranteed Renewability
Arizona requires guaranteed renewal for health insurance:
When Coverage Can Be Terminated
- Non-payment of premium (after grace period)
- Fraud or intentional misrepresentation
- Plan discontinuation (with proper notice)
- Moving out of service area
- Employer group no longer meets participation requirements
What health insurance marketplace does Arizona use for ACA coverage?
How long is the free look period for an individual health insurance policy sold to a 67-year-old Arizona resident?