Group Health Insurance Flashcards
Characteristics of group insurance
Insures many people in one contract
Usually less expensive than individual insurance
Sponsor receives the master contract
Participants receive certificate of insurance
Premium
- experience rating (based on claims history of individual group)
- Community rating (based more like individual insurance with pooling groups)
Eligible Groups
Group can’t exist for sole purpose of buying insurance
Employer sponsored Multiple employers combined (MET, MEWA) Labor Unions Trade or professional association Lender group (lender is paid, amount of insurance is not greater than debt)
Underwriting considerations
Size of group Composition of group Flow of members through group Plan design Contributory or non - C (employees pay part or all of cost, 75% participation) - n (employer pays entire cost, 100% participation) Persistency Administrative capability
Employee eligibility
Full time
Actively at work
Completed probationary time
Dependents eligibility
Spouse
Children younger than 26
Disabled child regardless of age
Enrollment eligibility
Follows probationary period
Usually no medical questions
Open enrollment
Usually once a year
No medical questions
Late enrollment
Will have medical questions
Coordination of benefits
Applies when a person is covered by two group policies
One plan is primary (pays first)
One plan is secondary (pays only if loss is greater than primary coverage)
Employee plan is primary
Children primary plan is determined by which parent’s birthday comes first in calendar year
Marketing considerations for group insurance
Advertising may not be misleading
Group policy is regulated in the state where employer has office
Change of insurers
No loss or gain in benefits for current claim
Termination of group coverage
Employer terminates plan
Employer didn’t pay premium
Employee quits, laid off, reduced hours
Dependents (divorce, employee dies, employee employment is terminated, too old)
Extension of benefits
Benefits paid by an in-force policy continue after the policy is terminated
Consolidated Omnibus Reconciliation Act (COBRA)
Federal law that employers woth 20 or more employees allow former employees and their dependents to continue the benefits provided by the employer group health insurance plan for 18-36 months
Employee must pay premium
Health insurance portability and accountability act (hipaa)
Preexisting conditions
Includes most health coverage
Guaranteed 48 hour hospital stay for new mothers after regular delivery or 96 hours after c-section
Small employers cannot be denied
