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IL Life and Health Insurance > Individual vs. Group Insurance > Flashcards

Individual vs. Group Insurance Flashcards

1
Q

The Individual Market is for…

A

Individuals and families

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2
Q

Individual Market: Who is the policy holder?

A

Buyer and can choose the policy/plan features

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3
Q

Individual Market: Change in employment has…

A

No impact on coverage

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4
Q

Until ACA, shoppers in the individual market could be denied insurance or charged more due to…

A

Personal health status

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5
Q

Applying for individual health insurance traditionally involved…

A

Some level of medical underwriting

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6
Q

Medical Underwriting

A

Health history and health-related habits, MIB files, Physicals

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7
Q

Even if medical underwriting is limited by the ACA in traditional health insurance…

A

It might still be practiced in disability/LTC markets

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8
Q

Individual Underwriting: Community Rating

A

Price based on collective health/characteristics of the larger population, not the individual

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9
Q

Individual Underwriting: Modified Community Rating

A

Price based on health of community with limited consideration of the individual

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10
Q

ACA plans must use modified community rating that only considers…

A

Family size, tobacco use, age, geography

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11
Q

ACA plans cannot use…

A

Gender and individual health

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12
Q

Group Health Insurance covers…

A

Several people via a “master policy”

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13
Q

Group Health: Policyholder is typically…

A

Employer

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14
Q

Group Health: Employee receives…

A

Certificate of insurance

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15
Q

Group Health: Typically can insure…

A

Employees, spouses, and dependent children

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16
Q

Group Health: Employee coverage often paid for by…

A

Employer and employee

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17
Q

Group Health: Dependent coverage often paid for by…

A

Employee

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18
Q

HIPAA prohibits discrimination (price and availability) based on…

A

Health if joining during open enrollment

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19
Q

Open Enrollment

A

Eligible employees, spouses, and dependents can typically enroll at the start of employment or during one month annual period

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20
Q

Open Enrollment: Don’t need to wait for annual period if…

A

Employee, spouse, or dependent loses other coverage; birth or adoption; marriage

21
Q

Open Enrollment: Traditionally, everyone is eligible regardless of health and often no waiting periods for pre-existing conditions if…

A

Had creditable coverage within 62 days of applying

22
Q

Group Health Insurance Underwriting

A

Premiums won’t depend on characteristics of any individual

23
Q

Group Underwriting: Experience-rated

A

Characteristics of the collective group will be a major impact on price (large group)

24
Q

Group Underwriting: Community-rated

A

Characteristics of the broader population will be a major impact on price (small group)

25
Q

Self-Insured Groups

A

Employer pays for employee care with its own funds

26
Q

Self-insured groups are often exempt from…

A

State insurance laws but still regulated by federal government

27
Q

Self insured groups admin duties are often handled by…

A

Third party administrator (TPA) or administrative services organization (ASO)

28
Q

Stop-loss insurance might kick in if…

A

Claims are significantly higher than premiums

29
Q

Coordination of Benefits

A

Addresses how claims will be paid when covered by multiple plans

30
Q

Coordinating Policies

A

Take other insurance into account

31
Q

Non-Coordinating Policies

A

Do not take other insurance into account

32
Q

COB: Individual

A

Claims are split pro-rata liability

33
Q

Pro-Rata Liability

A

Big plans pay more, small plans pay less

34
Q

COB: Group

A

Employee’s plan is primary, spouse’s plan is secondary

35
Q

COB, Group: Joint Custody

A

Parent with birthday earliest in the year is primary

36
Q

COB, Group: Not Joint Custody

A

Custodial parent’s coverage is primary for child, unless divorce says otherwise

37
Q

No Loss/No Gain

A

Applies if employers replace a health plan during the policy period

38
Q

No Loss/No Gain Qualities

A

No new restrictions on a pre-existing conditions; deductibles paid in same year might need to carry over

39
Q

Contributory Group

A

Each group member pays at least part of the premium; 75% minimum participation

40
Q

Non-Contributory Group

A

Plan sponsor pays full premium; 100% participation

41
Q

Contributory/non-contributory groups are done to prevent…

A

Adverse Selection

42
Q

Blanket Policy

A

Insurance for non-employer groups that have frequent changes in membership

43
Q

Blanket Policy: Insurer generally doesn’t receive…

A

List of group members

44
Q

Blanket Policy: Group members don’t receive…

A

Certificate of Insurance

45
Q

Blanket Policy: Typically only…

A

Accident insurance for medical care

46
Q

Employer Taxes

A

Can typically deduct its own contributions to employee health insurance from its income taxes

47
Q

Patient Taxes

A

Typically no taxes for benefits

48
Q

Patient Taxes: Premium contributions for group insurance are usually…

A

Pre-tax, excluded from taxable income so no extra deduction allowed

49
Q

Patient Taxes: Contributions of after-tax dollars for medical care/insurance might be taxable if…

A

Itemizing your taxes and spending more than 7.5% of income on heath care

IL Life and Health Insurance (29 decks)

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