Chap. 6 Flashcards
Q: How do insurers determine the cost for a group health policy?
A: The main variables are the ratio of men and women in the group, and the average age of the group
Q: What types of groups are eligible for group health insurance?
A: Employer-sponsored and association-sponsored groups
Q: If the insureds share in the cost of health insurance premiums with the employer, this would be known as what type of group health plan?
Contributory
Q: How many members must an association have to qualify for group insurance?
A: 100 members
Q: What do individual insureds receive as proof of their group health coverage?
A: Certificate of Insurance
Q: What is a probationary period in group health insurance?
A: The period of time that must lapse before an employee is eligible for group health coverage
Q: In health insurance, when would an excess plan pay benefits?
A: After the primary plan has paid its full promised benefit, the excess plan will pay the balance
Q: Does group health insurance require medical examinations?
A: No, the underwriter evaluates the group as a whole, rather than each individual member
Q: According to the Coordination of Benefits provision, if both parents have coverage for a child from their employers’ policies, which policy will pay first?
A: The order of payment will be determined by the birthday rule: the coverage of the parent whose birthday is earlier in the year will be considered primary
Q: What is the purpose of COBRA?
A: To allow continuation of health insurance coverage for terminated employees
To provide continuation of coverage for terminated employees
Q: What is a birthday rule in a coordination of benefits provision?
A: The coverage of the parent whose birthday is earlier in the year is considered primary
Q: If a group health policy covers individuals that reside in more than one state, which state has jurisdiction over the group policy?
A: The state in which the policy was delivered
Q: In group insurance, who is issued a certificate of insurance?
A: Individual insured
Q: Who are the parties in a group health contract?
A: The employer and the insurer
Q: In group insurance, what is the name of the policy?
A: Master policy
In a group policy, the contract is between
The employer and the insurance company.
In order to qualify for group coverage in this state, associations must insure
At least 25 members.
Which of the following statements is NOT correct concerning the COBRA Act of 1985?
It requires all employers, regardless of the number or age of employees, to provide extended group health coverage.
Which of the following statements concerning group health insurance is CORRECT?
The employer is the policyholder.
Accountable health plans cannot impose pre-existing condition exclusions on children adopted
Before age 18.
What type of group rating uses the actual experience of the group as a factor in developing the rates to be charged?
Experience rating
Which of the following is true regarding METs?
They allow several small employers purchase less expensive insurance together.
In the event of a divorce, which of the following would allow a divorcee to continue receiving group health coverage under an insured spouse’s plan for an additional 36 months?
COBRA
Which of the following is NOT the purpose of HIPAA?
To provide immediate coverage to new employees who had been previously covered for 18 months
Why do group health providers usually require a certain amount of participation in the plan by eligible employees?
To guard against adverse selection and reduce cost
HIPAA applies to groups of
2 or more.
Which of the following options best depicts how the eligibility of members for group health insurance is determined?
By conditions of employment
Which of the following would be a qualifying event as it relates to COBRA?
Termination of employment due to downsizing
Which of the following factors would be an underwriting consideration for a small employer carrier?
Percentage of participation
How many eligible employees must be included in a contributory plan?
75%
The classification “small employer” means any person actively engaged in a business that during the preceding year employed
At least 2 and not more than 50 persons.
If a firm has between 2 and 50 employees that are actively engaged in business during the preceding calendar year, what is its classification?
Small employer
Jason is insured under his employer’s group health insurance. He splits the cost of the premiums with his employer. This is an example of
A contributory plan.
In a noncontributory health insurance plan, what percentage of eligible employees must participate in the plan before the plan can become effective?
100%
An employee insured under a group health plan has been paying $25 monthly premium for his group health coverage. The employer has been contributing $75, for the total monthly cost of $100. If the employee leaves the company, what would be his maximum monthly premium for COBRA coverage?
$102
If an insurer terminates a small group disability plan’s coverage, it cannot issue those plans for
The next 5 years.
When employees are actively at work on the date coverage can be transferred to another insurance carrier, what happens to coinsurance and deductibles?
They carry over from the old plan to the new plan.
Who is the beneficiary in a credit health policy?
The lending institution
What is the benefit of experience rating?
It allows employers with low claims experience to get lower premiums.
Which of the following entities is automatically qualified to enroll in a health insurer’s mandatory, guaranteed issue policy?
All small employers
To protect personally identifiable information, state Exchanges must establish safeguards that include all of the following EXCEPT
Returning copies of paperwork featuring such information to individuals.
An insured is covered under 2 group health plans – under his own and his spouse’s. He had suffered a loss of $2,000. After the insured paid the total of $500 in deductibles and coinsurance, the primary insurer covered $1,500 of medical expenses. What amount, if any, would be paid by the secondary insurer?
$500
A man works for Company A and his wife works for Company B. The spouses are covered by health plans through their respective companies that also cover the other spouse. If the husband files a claim,
The insurance through his company is primary.
Which statement best defines a Multiple Employer Welfare Arrangement (MEWA)?
A joining together by employers to provide health benefits for employee
What type of information is NOT included in a certificate of insurance?
The cost the company is paying for monthly premiums
All of the following are differences between individual and group health insurance EXCEPT
Individual insurance does not require medical examinations, while group insurance does require medical examinations.
