Group Accident & Health Insurance and Dental Care Plans (CH 10)

Question 1

Adverse Selection

Answer 1

Selection against the insurance company. The tendency of poorer risks to want insurance more often than standard risks.

Question 2

COBRA

Answer 2

Consolidated Omnibus Budget Reconciliation Act (COBRA) passed by Congress in 1986. The law enables a former employee to continue with his or her health coverage at the former employee’s own expense.

Question 3

Community Rating

Answer 3

A method of HIC rate calculation where the rate charged to a group or individual for the HIC coverage is based on the profit or loss experience of the HIC’s entire population.

Question 4

Contributory Group Policy

Answer 4

Group insurance for which the employees pay part of the premium. A minimum of 75% of eligible employees must participate.

Question 5

Credible Coverage

Answer 5

Any previous health insurance coverage a person had before buying a Medi-gap policy, as long as there was no break in coverage of more than 63 days.

Question 6

Experience Rating

Answer 6

The loss record of an insured, a class of coverage, or an insurance company.

Question 7

Non-contributory Policy

Answer 7

Any plan or program of insurance (usually group) for which the employer pays the entire premium and the employee contributes no part of the premium. Participation must be 100%.

Question 8

Persistency

Answer 8

The length of time that a group case stays on the books of the insuring company; impacts the group rate.

Question 9

Pre-existing Condition

Answer 9

A condition of health or physical condition that existed before the policy was issued.

Question 10

Individual Employer Plans

Answer 10

Self employed or partnerships in which the individual owner may have an individual policy or a group plan. Partner considered to be owners of the business and in some cases these individuals could be set up as employees of their business.

Question 11

Multiple Employer Trust (MET)

Answer 11

A trust consisting of multiple small employers in the same industry, formed for the purpose of purchasing Group Health Insurance or establishing a self-funded plan at a lower cost than what is available to the employers individually. MET’s are managed by an attorney-in-fact/

Question 12

Multiple Employer Welfare Arrangement (MEWA)

Answer 12

Any plan established or maintained by an employer or by an employee organization. Its purpose is to provide for its participants or their beneficiaries often on a self-insured basis, medial, surgical, or hospital care or benefits, or benefits in the event of sickness, accident, disability, and death.

Question 13

Preventative and diagnostic care

Answer 13

office visits, examinations, cleaning, X-rays, and diagnostics

Question 14

Restorative Care

Answer 14

fillings, inlays, and crowns

Question 15

Prosthodontics

Answer 15

Bridgework- artificial teeth as a prosthesis

Question 16

Oral Surgery

Answer 16

such as removal of wisdom teeth

Question 17

Periodontics

Answer 17

treatments of gum problems

Question 18

Endodontics

Answer 18

procedures such as root canals

Question 19

Orthodontics

Answer 19

braces

Question 20

When a corporation established a non-contributory group medical insurance contract, what percentage of eligible employees must enroll for the insurance to be issued?

Answer 20

100% of eligible employees

Question 21

Being defined as a “true group” means

Answer 21

the employees who enroll in the insurance plan do not have to answer any medical questions.

Question 22

Who has regulatory control over the group insurance contract?

Answer 22

State where the master policy is delivered.