Group Health Insurance Flashcards
Under group Health insurance, each participant gets a, “___”?
Certificate of coverage
Most states require at least ____ amount of employees for an employer to qualify for standard group insurance?
at least 10 employees
Terminated participants can convert group coverage to an individual policy without what?
Without proving insurability
True or False-
No individual or group medical plan can exclude coverage of existing conditions for any adult applicant or independent.
True
Why does it cost less to insure an individual under a group plan rather than a individual plan?
B/c the administrative costs and risks are spread over many people and not just one.
Whats the difference between a ‘Group’ self insured plan, and a fully insured plan?
in a self insured plan the employer pays the claims. In a fully insured plan the insurance company pays the claims.
Noncontributory plans must cover ___ percent of group members eligible to participate?
100%
Contribuatory plans require participation from at least ____ % of group members eligible to participate?
75%
Why does an insurer require that a certain percentage of eligible members participate in group health insurance plan?
To avoid adverse selection
Who determines the length of the waiting period in group health insurance?
The employer and the insurer
What law prohibits employers from discriminating against those who are at least 40 years old?
Age discrimination in Employment Act (ADEA)
The womens health and cancer rights act requires group plans that cover mastectomies to also cover what?
to cover breast reconstruction
FMLA requires employers *with at least 50 employees) to provide how many weeks of unpaid leave for family and personal medial reasons?
12 weeks unpaid leave
What allows employees who are terminated other than gross misconduct to continue group coverage for up to 18 months by paying 102 % of the premium?
COBRA
The patient protection and affordable care act (PPACA) prohibits health insurers from excluding coverage for ___?
Prohibits excluding coverage for pre-existing conditions
Employers with fewer than how many employees are exempt from COBRA?
20
When a person exhausts health insurance coverage under COBRA, HIPPA guarantees that the person will____?
The person will have access to a guaranteed-issue individual health insurance policy, regardless of health.
HIPPA requires insurance companies that sell individual health insurance policies to offer them to eligible people who have lost ____ regardless of ____?
lost group coverage regardless of their health.
Which federal law regulates group health plans and protects their enrollees?
ERISA (Employee retirement income safety act)
What does Cobra guarantee to an employee who voluntarily leaves an employers insured group?
COBRA guarantees the employee the right to continue coverage at the EMPLOYEE’S expense for up to 18 months.
Which governments regulate group health insurance?
A. State
B. Federal
C. Both State and Federal
C. Both state and federal
Dependents who lose coverage due to divorce or death may extend coverage up to how long under this Law?
up to 36 months under COBRA
What Law requires copayments, deductibles, and limitations on treatment for mental health or substance abuse CANNOT be more restrictive than those for other medical benefits?
This act applies to employers with how many employees?
MHPAEA (Mental health parity and addiction equality act)
-Applies to employers with more than 50 employees
What is the purpose of COBRA?
To let those who are no longer employed continue their group’s coverage for up to 18 months.
Unless due to divorce or death extension can be up to 36 months.
FORMER EMPLOYEE PAYS PREMIUM
Under COBRA- If a medicare eligible participant loses group coverage, the YOUNGER spouse may continue group coverage with medicare benefits even if?
They can still get those Medicare benefits EVEN if the younger spouse is not eligible for Medicare coverage yet. (age 65, etc. )
When does COBRA coverage end?
(3 things)
1.After Maximum coverage time period
2. If person is eligible for another group plan
3. If the person fails to pay their premium
What law ensures that those who have lost their job or want to change health insurance carriers will continue to qualify for medical insurance when they go to another job?
-This definition is called what under this law?
HIPPA –definition of Portability.
HIPPA guarantees that insurers who sell individual health insurance plans must offer them to eligible people who have lost group coverage, regardless of their health. This is called what?
Guaranteed issue
Under HIPPA- to be eligible, a person must have exhausted all available COBRA coverage.
Those who are terminated from a group plan and decline COBRA coverage are ____ for a guaranteed issue policy?
NOT ELIGIBLE
Group health plans usually provide coverage for how long before renewing?
one year
What is No Loss/No Gain AKA No loss of coverage?
If an employer changes plans/insurers, employees CANNOT lose their right to coverage.
When an employer gets a new group health insurance plan or insurer, the new plan or insurer CANNOT require a covered employee to do what?
CANNOT require the employee to satisfy a new probationary period, or pay a new deductible IF the employee already did these under the previous plan.
Small employers are usually defined as having how many employees?
2-50 employees.
Some states define it as having as few as 1 employee
Most states define an eligible employee as one who works for an employer AT LEAST how many hours each week?
25 hours a week
What does noncontributory mean, and the plan must cover who?
Non contribuatory= employer pays entire premium and it must cover ALL eligible employees
What does a contributory plan mean?
A group plan that BOTH employer and employee pay the premium.
**Employer must pay at least 10% of the group medical insurance premium.
With a contributory plan, what percent of eligible employees must participate in the plan?
contributory plan=at least 75% must participate
