Unit 18 Flashcards
Group insurance has how many contracts
One
Is group or individual insurance typically cheaper
group
Participants of group insurance receive a
Certificate of Insurance
Group insurance contracts are called
Master Contracts
Types of premiums establishing for group insurance
Experience Rating, Community Rating
Group insurance sizes
Small 2-50, Large 51+
Group underwriting considerations
Size, Composition, Flow, Plan Design, Contributory/ Non- Contributory, Persistency, Admin Capability
What does a Contributory Group insurance plan mean
Employees contribute to the premiums costs and at least 75% must participate
What does Non Contributory group insurance mean
Employers pay premiums and 100% of employees must participate
What is a Probationary period
period for new employees before eligible for enrollment (1-6 mo)
When does the Eligibility/ Enrollment period for group insurance begin and how long does it last
When the probationary period has ended and 30-31 days
Late enrollees to group insurance may be required to provide what
Proof of insurability
Basic requirements for employer sponsored group insurance
Full time, Actively at work, Available to Children under 26 (or over if disabled)
What is the Coordination of Benefits provision
Provision elaborating of the protocols for when an individual is a beneficiary to 2 group insurance plans
What is the Birthday rule
Used to determine which parent’s health policy is primary for children (The parent who’s bday is earlier in the year)
Who regulates the marketing of Health and Accident insurance
Individual states
Should an insurer sign up for group insurance with a foreign insurer what happens
The transactions are overseen by insurance regulators from both states
Group Insurance is regulated by what state
The state that the employers principal office is located
What is No Loss, No Gain
Statues that many states have stating that ongoing (disability) claims must continue if the employer was to switch policies, without imposing the new plans eligibility requirements
What is COBRA
Federal law that requires employers with 20+ employees to allow former employees to continue their coverage under certain circumstances
How long does COBRA allow coverage to continue
18-36 mo
Who is required to pay the entirety of the premium in a COBRA policy
The participant
What occurs when a qualified beneficiary loses coverage under a group plan
Qualifying Events
An individual covered under an employer-maintained group policy
Qualified Beneficiary
What type of termination is excluded in Qualifying Events
Gross Misconduct
How long does an employer have to notify of eligibility for COBRA continuation
14 days
How long does one have to sign up for COBRA continuation
60 days from time of notification
When should new employees be notified of COBRA rights
when informed of benefits
How should spouse/dependents be notified of COBRA rights
In writing and sent by mail to last known address
Max Continuation for reduction of hours
18 mo
Max continuation for other qualifying events
36 mo
Premium overdue, Employer ceases plan, Individual is covered by a different plan, individual becomes medicare eligible
Disqualifying Events
How much will a participant pay during a COBRA extension
100-102%
What did the OBRA act of 1989 do
Extended the minimum extension period for those disabled upon termination to 29 mo
How much does a participant pay while partaking in the extension provided by OBRA and when
up to 150% from months 19-29
When did HIPAA take effect
July 1st, 1997
What is the definition of a pre-existing condition under HIPAA
A condition in which medical advice, diagnoses, care, or treatment was recommended or received during the 6 mo prior to the enrollment date
How long can Pre-existing condition be excluded under HIPAA
up to 12 mo, 18 mo for late enrollment
What is creditable coverage
As long as there wasn’t a break 63+ days in coverage, creditable coverage reduces the max pre-existing conditions exclusion period for new plans
What guarantees new mothers 48 hr hospital coverage (96 for csections) and mental illness coverage similar to that of physical conditions
Mandated Benefits
What does Privacy Disclosures do in HIPAA
imposes specific requirements to those with access to medical and health information
What notices must an insurance applicant receive
Insurer’s privacy policy, Right’s to maintain privacy, Opportunity to Opt-out, Notice of Insurance information practices
What does ERISA stand for
Employee Retirement Income Security Act
What does ERISA do
sets detailed standards for those managing employee welfare plans and requires certain information pertaining to plans be available
