group health

What is a group health plan

A policy that covers many people under one contract that reduces plan costs and lowers premiums

What is an experience rating in group health plans

A method of establishing premiums based on previous claim experience

What is a community rating group insurance

A method of establishing premium costs by using the same rate structure for all subscribers, regardless of past loss experience by the insurer

What is a met

A multiple employer trust is a group of small employers in the same industry who form a trust to purchase group insurance as one entity

What is a mewa

A multiple employment welfare arrangement provides health and welfare benefits to two or more unrelated, employers typically small businesses

What is an association group plan

When multiple trades or professions sponsor a group plan for its members

If a group health plan is offered under a labor union, they are sponsored by

A taft-Hartly trust

A lender or creditor May sponsor a group health or disability plan for its group of debtors. This is known as

A group credit disability insurance

What are the two features that make up a group credit disability insurance

Group credit disability insurance is payable to the sponsoring group and the amount of coverage is limited to the amount of the insurance debt

How is an employer group health insurance? Underwritten

By the size of the group, the composition of the group, the flow of members through the group, plan design, contributory or non-contributory, persistency, administrative capability

For employer group underwriting, the size of the group matters because

Larger groups can more likely avoid adverse selection

What is considered a small group and what is considered a large group in employer group health underwriting

Small groups are 2 to 50 people. Large groups are 51 or more people

An employer group underwriting what is taken into consideration for composition of the group

Age, sex and income of the members

For employer group health underwriting, why does the flow of members through the group matter

Individuals joining and leaving the group on a regular basis reduces the risk of adverse selection

How many members must participate in contributory and non-contributory plans

For contributory plans at least 75% for non-contributory plans 100%

What is persistency in employer group health underwriting

When an employer keeps their group coverage with the same insurer every year, then expenses can be reduced

An employer group underwriting administrative capability refers to

Employers helping lower group premium costs by assisting to administer the plan and use the insurer for stop loss coverage or claims processing only

Employers can establish basic employment criteria to qualify for a group plan the employee must be

Full-Time and actively at work

What types of dependents can be included on an employee group plan

Spouse children up to age 26 and dependent parents

How long is the typical probationary period for an employer group plan

1 to 6 months

How long is the typical eligibility or enrollment. For a group health plan

30 or 31 days

Late enrollees in a group health plan may be required to provide

Evidence of insurability

If an individual is over insured it means

They're able to collect benefits in excess of the amount of loss they experience

To avoid an individual being overinsured group health insurance policies contain what provision

A coordination of benefits provision

Under the coordination of benefits provision what happens if a loss is payable under two group health insurance plans

One coverage is considered primary and the other is considered secondary

How is a primary plan and secondary plan determined

Either your employer plan is your primary plan or it can be determined based on the birthday rule

What is the birthday rule under the coordination of benefits provision

Only in place for a married couple. Has children, the parent whose birthday comes earliest in the year will use their plan as the primary coverage for the children. The remaining parents plan is secondary

Under the birthday rule, if both parents are born on the same day, how do you determine the primary policy

Whichever policy has been in place, the longest will be primary

For children whose parents are separated or divorced, who both have group coverage on the child whose plan is primary

The plan of the parent with custody is primary barring any other legal arrangements

Many states have statutes that require benefits for ongoing disability claims that started under an old plan to continue without imposing a new plans eligibility results this is called

No loss, no gain statute

What are some examples of reasons a group health plan may be terminated

The employer discontinues the plan, non-payment of premium from either the employer or the employee, the covered employee quits is laid off or loses full-time status, the spouse and children lose connection to a plan due to a divorce, a non-disabled dependent reaches age 26

Who is an extension of benefits typically offered to

A totally disabled member at the time of the policy discontinuance

What is the consolidated omnibus budget reconciliation act

Cobra

Under federal law, employers with 20 or more employees must allow former employees and their dependents to continue provided benefits under group plans for 18 to 36 months. This is covered under

The consolidated omnibus budget reconciliation act or Cobra

What are qualifying events under the consolidated omnibus budget reconciliation act

Death of a covered employee, termination of a covered employee except for gross misconduct, reduction of work hours, Medicare eligibility for the employee, divorce or legal separation, termination of a child's dependent status, bankruptcy of the employer

Who is considered a qualified beneficiary in an employer maintained group health plan

Covered employees, spouses and independent children of covered employees

Under the consolidated omnibus budget reconciliation act, federal law employers must provide notification statements to individuals that are eligible for Cobra continuation within how many days

30

How long is the Cobra election period

60 days

What is the maximum period of coverage continuation under Cobra

For termination of employment or reduction in hours 18 months, for all other qualifying events. 36 months

What are the disqualifying events that can result in Cobra termination of coverage before the specified time period

Non-payment or overdue premium, the date on which an individual is covered by another group plan or becomes eligible for Medicare

What are some key factors of the continuation of group coverage offered through Cobra

The benefits offered must be the same that the insured had while employed except the employee must pay the entire premium and possibly an additional 2% to cover administrative expenses

The omnibus budget reconciliation act of 1989 or obra is what

A continuation of Cobra coverage for a period of 29 months for qualified beneficiaries disabled at time of termination

Under and OBRA continuation qualified beneficiaries can receive a premium increase of up to

150 times the group premium during the 11-month disability extension

What are the important characteristics of group health insurance under the health insurance portability and accountability act or HIPAA

Pre-Existing conditions. Credible coverage. Mandated benefits privacy disclosures

Under HIPAA, what constitutes a pre-existing condition

A condition in which medical advice, diagnosis, care or treatment was recommended or received 6 months prior to the enrollment date of a plan.

Under HIPAA what is credible coverage

Credible coverage States that if an individual had prior credible coverage. (Most health coverage. Qualifies) Of 12 months or more and there was not a gap of 63 days between coverage on a prior plan and the new plan. Then the new plan cannot apply pre-existing condition exclusion

What are mandated benefits under HIPAA

Guaranteed 48-hour hospital stay for new mothers 96 for cesarean section birth, required expanded coverage for mental illness, small employers cannot be denied group health coverage due to poor health of employees

Under HIPAA an applicant must be given notice of the following

An insurer's privacy practices, right to maintain privacy, opportunity to opt out, notice of insurance information practices

Under the employee retirement income security act or erisa, what documentation must be provided and to who

A summary plan description to each participant and the department of Labor. A summary of material modifications to each participant in the department of Labor. Annual return form 5500 to the IRS. A summary annual report to each participant and any terminal report to the IRS

Who does erisa protect

Employees and beneficiaries