Group Health Insurance Flashcards

1
Q

Characteristics of group insurance

A

Insures many people in one contract
Usually less expensive than individual insurance
Sponsor receives the master contract
Participants receive certificate of insurance
Premium
- experience rating (based on claims history of individual group)
- Community rating (based more like individual insurance with pooling groups)

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2
Q

Eligible Groups

A

Group can’t exist for sole purpose of buying insurance

Employer sponsored 
Multiple employers combined (MET, MEWA)
Labor Unions
Trade or professional association 
Lender group (lender is paid, amount of insurance is not greater than debt)
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3
Q

Underwriting considerations

A
Size of group
Composition of group
Flow of members through group
Plan design
Contributory or non
- C (employees pay part or all of cost, 75% participation)
- n (employer pays entire cost, 100% participation)
Persistency
Administrative capability
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4
Q

Employee eligibility

A

Full time
Actively at work
Completed probationary time

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5
Q

Dependents eligibility

A

Spouse
Children younger than 26
Disabled child regardless of age

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6
Q

Enrollment eligibility

A

Follows probationary period

Usually no medical questions

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7
Q

Open enrollment

A

Usually once a year

No medical questions

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8
Q

Late enrollment

A

Will have medical questions

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9
Q

Coordination of benefits

A

Applies when a person is covered by two group policies
One plan is primary (pays first)
One plan is secondary (pays only if loss is greater than primary coverage)
Employee plan is primary
Children primary plan is determined by which parent’s birthday comes first in calendar year

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10
Q

Marketing considerations for group insurance

A

Advertising may not be misleading

Group policy is regulated in the state where employer has office

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11
Q

Change of insurers

A

No loss or gain in benefits for current claim

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12
Q

Termination of group coverage

A

Employer terminates plan
Employer didn’t pay premium
Employee quits, laid off, reduced hours
Dependents (divorce, employee dies, employee employment is terminated, too old)

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13
Q

Extension of benefits

A

Benefits paid by an in-force policy continue after the policy is terminated

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14
Q

Consolidated Omnibus Reconciliation Act (COBRA)

A

Federal law that employers woth 20 or more employees allow former employees and their dependents to continue the benefits provided by the employer group health insurance plan for 18-36 months

Employee must pay premium

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15
Q

Health insurance portability and accountability act (hipaa)

A

Preexisting conditions
Includes most health coverage
Guaranteed 48 hour hospital stay for new mothers after regular delivery or 96 hours after c-section
Small employers cannot be denied

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16
Q

Employee retirement income security act (ERISA)

A

Protects employee and beneficiary
Plan deals with qualified pensions and also group insurance
ERISA requires that certain information be able to plan participants, beneficiaries, and Dept of labor