Group Insurance Flashcards
What is the policyowner responsible for (3)
- Applying for coverage
- Keeping the policy in force
- Paying premiums
What are 5 provisions cited in the master policy
- Explain eligibility requirements
- Establish when coverage is effective
- State the minimum number of persons and percentage of the group which must be covered
- Establish coverage limits for members
- Cite the duties of the master policyowner
What is the certificate of insurnace
It is evidence of coverage (basically the handbook)
When comparing individual policies to group contracts, generally group contracts have:
- Higher maximums
- Broader benefits
- Fewer exclusions
- Less stringent underwriting
Does COB affect payments from individual disability insurance
No
Who pays if a child is enrolled under both parents
The parent with the earliest birth date in a calendar year pays first (January will pay before February)
What are three employment-related groups
- Individual employer groups
- Multiple employer trusts (MET)
- Multiple employer welfare arrangements (MEWA)
What is a MEWA
It is a type of trust, that provides benefits to employees of two or more employers within a specific industry
Does an employee have to become a member of MEWA
Yes, if they want to receive benefits, then they become a member of the trust
Can MEWA be both fully insured and ASO
Yes
What is different about a MET from a MEWA
A met is a type of MEWA, but it has to be fully insured
What are three requirements in order for an association to provide group health insurance
- Have had an existence for at least one year
- Have a constitution and bylaws
- Did not get together in order to have insurance
Who is the policyholder in associations
The association is the policyholder
What are two requirements for self-funded groups
- The law of large numbers enables accurate estimates of losses
- Enough assets to cover any losses
What if a self insurer does not have enough in assets to cover employees
Then they must have stop-loss insurance
To underwrite group insurance, what does the underwriter take into consideration
- Who is eligible to enroll (high risk versus low risk)
- Geographic area
- Composition of the group (age and gender)
- Percentage of eligible members participating
Define adverse selection
When people with high risk join and raise the premium price, then low risk members will leave due to the higher premiums
Under a contributory plan, where the member pays part of the premium, how many members must participate
75%
Under a noncontributory plan, where the member does not pay any part of the premium, how many members must participate
100%
Define persistency factors
The insurer will consider whether the group changes insurers frequently, because we don’t want a group that moves around a lot, because the initial underwriting numbers cost more
How are the premiums for groups determined
They are based on their experience rating
What does experience rating take into account
- Average age of the group members
- Coverage limits and deductibles
- Occupational hazards
Define doctrine of comity
The state in which a group policy is delivered to the policyowner has regulatory jurisdiction, which means that the policy has to follow the laws of that state regardless of where members are living
What happens if the group changes carriers before the renewal (mid-year change). How are claims paid?
- The new plan would pay the difference between the amount it would have paid and the amount payable under the original plan (basically cover any amounts leftover, so the member doesn’t notice a difference)
Define the no loss-no gain statues
Prohibit the replacing carrier from denying benefits to members who have existing claims filed with the previous carriers
What does COBRA stand for
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Once your coverage is terminated, how long do you have to elect COBRA coverage
60 days
Under COBRA how much will you have to pay
100% of the premium plus 2% admin fees
What are 3 reasons to have COBRA coverage for 18 months
- Reduction in hours
- Termination of employment
- Layoff
What is the reason to have COBRA coverage for 29 months
Disability
What are 5 reasons that a dependent could receive coverage for 36 months
- Employee’s death
- Divorce
- Separation
- Eligibility for Medicare
- Child aged off
What are 3 reasons why a member may not be eligible for COBRA
- Termination was due to the member not paying premiums
- Employee gains group coverage or Medicare
- Employer terminates all group plans
What does HIPAA stand for
Health Insurance Portability and Accountability Act of 1996
As far as gaining new coverage, what was one of the purposes of HIPAA
Made insurance portable, by allowing members that have changed jobs to obtain new group health coverage without having to satisfy a new pre-existing condition period or a new probationary period
What are 3 examples of PHI that HIPAA says you can’t share
- Individual’s health (mental and physical)
- Care provided to the individual
- Payments made for the individual to receive care
When can a covered entity share PHI (2)
- With written authorization of the patient
- As permitted under the Rule
When does a covered entity have to provide PHI upon request to: (2)
- An individual or representative
- Department of Health and Human Services
What must covered entities state in their privacy noticies
- It’s duties to protect privacy
- An individuals’ rights
- Contact information if an individual needs more information or has a complaint
What plans are not subject to HIPAA
Pretty much everything but Medical, dental and Medicare
Under HIPAA, a group health plan may not discriminate on what? (6)
- Health status
- Health history
- Genetic information
- Disability
- Mental illness
- Claims experience
What is the maximum number of months that a plan can have a pre-existing conditions limitations
12 months
What is the maximum number of months that a plan can have a pre-existing conditions limitations for late enrollees
18 months
How can a member reduce the pre-existing condition limitation
If they have creditable coverage and enroll in new coverage within 63 days of termination from prior coverage
What are examples of plans that are creditable
- Group
- COBRA
- HMO
- Individual
- Medicare
- Medicaid
What are some examples of plans that are not creditable
Limited policies such as dental or vision
Under the pre-existing conditions limitations, within how many months would a pre-existing conditions limitations be set
Limitations would only apply if it is a condition that was or should have been treated within 6 months prior to enrollment
Can pregnancy be considered a pre-existing condition and thus excluded
No
During open enrollment period, what is the pre-existing condition limitation
States that an insurer may look back no more than 6 months to determine if a pre-existing condition exists, and if found, can only exclude that condition for a maximum of 6 months (total of 12 month look back period)
What is the look back period for a late enrollees
6 months before and 12 months after enrollment (total of 18 month look back period)
How do commercial insurers pay for hospital and medical coverage
On a reimbursement basis
Who is reimbursed in commercial insurance
The member is reimbursed for any portions that they paid
How does the provider get paid in the reimbursement model for commercial insurance
The insured may assign the insurance proceeds to the provider so that they can be paid directly
Define a closed panel HMO
It is an HMO that has its own doctors and members must see these doctors
Define an open panel HMO
HMO will contract with doctors to provide services to their members, however, the contracted doctors may also treat other members who are not in the HMO
What does each member in HMO have to choose
A PCP
In an HMO, who is the gate keeper
The PCP and they offer referrals to specialists when necessary
Do you have deductibles and coinsurance in HMO
No
What does a member have to pay for when they go see a doctor in an HMO
They have to pay a copayment (could be a dollar amount or a percentage)
Define an opt-out provision
Allows a member to see OON providers (benefits may be reduced and there may be a deductible)
What is similar about PPO to an HMO
PPOs can also be formed on an open and closed panel basis.
What is an open panel PPO
It is a fee-for-service model
What does EPO stand for
Exclusive provider organization
Define an EPO
You can use any provider within the EPO network, however, you cannot receive OON benefits
Define a point-of-service (POS) plan
Allows a participant to seek treatment within an HMO or PPO network or from an OON on a major medical basis
How does a POS plan work with OON
It’s like our coverage (higher OON deductibles and copays)
What are two different types of POS plans
- Open ended HMO
- Gatekeeper PPO
What are the three payments for HMO, PPO and POS plan
- HMO is a prepaid plan
- PPO Fee for service plan
- POS plan is a fee for service when using OON
What type is more comprehensive
An HMO (ex - covering labs and home health care)
What types may have a more limited range of services
PPOs and POSs
What are three plan types that are forms of managed care
- HMOs
- PPOs
- POSs
What does managed care try and do to help control costs
- Cost control techniques
- Sharing of financial risk between providers and consumers
- Management of the use of health care services
In order to help control costs, how does managed care help shift some of the costs to the members
- Deductibles
- Coinsurance
- Exclusions and limitations
- Benefit maximums
In order to help control costs, what are methods that managed care uses (besides shifting cost to the member)
- Have a PCP act as a gatekeeper
- Offer benefits that could result in a less costly claim
- Provide prevention care benefits (physical exam)
Who can select the surgeon for a second opinion
The insurer
How do the costs work with a second opinion
Insurance would cover the second opinion or reduce benefits if the second opinion is not obtained or the member elects the surgery even though the second opinion said that they didn’t need one
Define precertification
Prior authorization - the insured will provide full benefits if this is obtained
What if no precertification is granted
Then benefits could be paid at a lower level or not at all
Define concurrent review
Monitoring a patient’s hospital stay in terms of length and seeing if other alternatives will work
What are 4 benefits included in workers comp
- Medical
- Disability income
- Death or survivor
- Rehab
Can an employer self insurer for workers comp
Yes
How are medical benefits covered under workers comp
Will cover medical, surgical, hospital, nursing, ambulance, drugs, and medical devices without any time limit, dollar limit, deductible or copay (basically cover everything without having the member pay)
What are two things that determine how much and for how long workers comp will pay for disability income
- How much in wages the member lost
- Whether the disability is total or partial and permanent or temporary
What is provided under death and survivor benefits under workers comp
Covers the cost of burial and provides income to the unmarried spouse and dependent children
How does sick leave and vacation work if a member is off work due to disability
The member will accrue sick and vacation leave while they are off of work
Under HIPAA, can the limitations for pre-existing conditions be reduced based on the length of creditable coverage
Yes
