Group Health Insurance II Flashcards
Pregnancy Discrimination Act of 1978
- Amendment to the Civil Rights Act of 1964 to “prohibit sex discrimination on the basis of pregnancy”
- It requires employers to treat pregnancy in the same manner as a disability for any other medical reason.
Pregnancy Discrimination Act of 1978 - Guidelines
- When medical benefits are offered, pregnancy must be covered the same as other illnesses
- Pregnancy must be treated the same as any other type of disability as to sick-leave plans
- Complications arising from abortion are covered ONLY if the life of the woman is endangered
Group Health Insurance Coverage in Multiple States
When that occurs, the coverage is controlled by the laws of the state where the master contract is issued.
Group Health Insurance Coverage for 65+
Working people age 65 or over generally must be offered the same accident and health benefits offered to younger employees
Dental, Vision, and Hearing Care – Dental Coverage
- Normal dental maintenance costs, such as annual checkups, teeth cleaning, etc. +
- Oral surgery, root canal therapy, and orthodontia
Dental, Vision, and Hearing Care – Dental Coverage Requirements
- reasonable and customary: the normal or acceptable range of payment for a specific health-related service or medical procedure; or
- “dollar-per-service” schedule: you choose the doctor or the hospital or the clinic, and the insurance pays for part or all of the cost according to a schedule laid out in the policy.
Dental, Vision, and Hearing Care – Dental Coverage
Co-pay & Deductibles
- Typical
- Some policies will cover routine cleaning and exams at 100%
- Plans generally limit the number of covered routine exams and cleanings each year
- Normally the coverage sets the maximum annual benefits amount, e.g. $1,000 or $2,000
Dental, Vision, and Hearing Care - Vision Care
- Pays for reasonable & customary charges during eye exams by ophthalmologists and optometrists
- Fitting expenses + contact lenses/eyeglasses cost partially covered
- Lasik surgery normally excluded
- Under the Affordable Care Act, pediatric dental & vision benefits are mandatory
Dental, Vision, and Hearing Care - Hearing
- Some private health care plans cover the costs of audiologic tests, a hearing aid evaluation
- Even partial or full coverage of a hearing aid
- Audiologic: The study of hearing disorders and the rehabilitation of people with hearing impairments.
Group Basic Medical Expense – Standard Forms
- Hospital
- Surgical
- Physicians’
A group basic medical expense plan can combine >=2 coverages, or
It may only cover one item, e.g. hospital expense only
Group Basic Medical Expense - New Coverages
Developed in recent years:
- Dental & vision
- Prescription drugs
- Home health care
- Extended care facilities
- Diagnostic x rays
- Lab services
Dental & vision only available on a group basis.
Group Major Medical Plans –
Comprehensive Major Medical
- a single, comprehensive plan
- Participants are usually required to satisfy an initial deductible
Group Major Medical Plans –
supplemental major medical
- Superimposed over a group basic plan
- Participants usually are required to pay a corridor/an integrated deductible
Benefits of Group Major Medical Plans vs.
Individual Plans
More extensive than individual plans
- E.g. offering individual benefit maximums of $1 million or do not set any maximum benefit limits;
- Deductibles are lower, typically $250-500, vs. $1,000 + for individual policies
- Coordination of benefits provision + maternity benefits vs. no such benefits in individual plans
Coordination of Benefits - Purpose
- Found only in group plans
- Purpose – to avoid duplication of benefit payments and over insurance when an individual is covered under multiple health plans.
