Group Health Insurance

In group health insurance, what does the employee receive which shows the amount of coverage?

a certificate of coverage it tells what is covered, how to file a claim, how long it'll last, and how to convert to individual policy

In a group policy, the contract is between A. the individual and the insurance company B. the employer and the union C. the employee and employer D. the employer and the insurance company

D

How many eligible employees must be included in a contributory plan? a. 75% b. 90% c. 100% d. 50%

A

In group insurance, what is the policy called? a. certificate of insurance b. master policy c. entire contract d. certificate of authority

B

An insured is covered under 2 group health plans - under his own and his spouse's. He had suffered a loss of $2,000. After the insured paid the total of $500 in deductibles and coinsurance, the primary insurer covered $1,500 of medical expenses. What amount, if any, would be paid by the secondary insurer? A. $0 B. $500 C. $1000 D. $2000

B Once the primary insurer has paid the full benefit, the secondary insurer will cover what the first company will not pay, such as deductibles and coinsurance. The insured will, then, be reimbursed for out-of-pocket costs.

Which statement best defines a Multiple Employer Welfare Arrangement? (MEWA) A. government health plan that provides health care for the unemployed B. group health plan that covers medical expenses arising from work related injuries C. joining together by employers to provide health benefits for employee D. plan that provides hospice care for terminally ill employees

C

When compared with the administrative cost found in additional coverage, the per capita administrative cost in group health insurance is A. higher B. comparable C. equal D. lower

D

What is the purpose of participation requirements for plans?

It protects the insurer against adverse selection and reduced administrative costs.

According to the Coordination of Benefits (COB) provision, when a married couple both has their own coverage and are listed as dependents on the other's, which is the primary?

The primary insurance would be each person's own coverage.

What types of groups are eligible for group insurance?

employer sponsored and association sponsored

What are the eligibility requirements for group health?

they must be full-time and employed 1-3 months

An insured has a primary group health plan and an excess plan, each covering losses up to $10,000. The insured suffered a loss of $15,000. Disregarding any copayments or deductibles, how much will the excess plan pay? A. $10,000 B. $7,500 C. $5,000 D. $0

$5,000

What type of events would terminate coverage for an employee?

-employment is terminated -eligibility ceases -overall maximum benefit is received -end of the last period for which they've made requirement payments has been reached -master contract is terminated

Do employees experience loss of coverage when their employers change insurance?

No, employees actively at work during the switch are automatically covered under the new policy and are exempt from probationary period. If the employee is not actively working, benefits may be limited to the prior plan's level until they return.

Under COBRA, when are dependents covered and for how long?

it requires any employer with 20 or more employees to extend group health coverage to terminated employees and their families after a qualifying event. For any of these qualifying events, coverage is extended for up to 18 months.

What is a creditor group? What is the purpose of it?

specialized use of group life and group health insurance that covers debtors (borrowers). protects lender from losing money due to borrower's death or disability.

As it pertains to group health insurance, COBRA stipulates that A. group coverage must be extended for terminated employees up to a certain period of time at the former employee's expense B. retiring employees must be allowed to convert their group coverage to individual policies C. terminated employees must be allowed to convert their group coverage to individual policies D. group coverage must be extended for terminated employees up to a certain period of time at the employer's expense

A

In a noncontributory health insurance plan, what percentage of eligible employees must participate in the plan before the plan can become effective? A. 100% B. 75% C. 50% D. 25%

A

In order to be eligible for group health insurance, all of these conditions an employee must meet EXCEPT A. must have dependents B. must be working in a covered classification C. must be actively at work D. must be a full-time employee

A

What are the requirements of terminated employees to convert the group health insurance to an individual plan without evidence of insurability?

this option must be initiated during the conversion period, which is within 31 days of termination of employment. The insurer is allowed to evaluate the individual in order to determine the appropriate premium, either standard or substandard, but they may not deny coverage based on this evaluation. The converted policy neither needs to provide the same benefits as the group, nor will it have the same premium. It will have lesser benefits and a higher premium.

In a group policy, who is issued a certificate of insurance? A. the individual insured B. the health care provider C. the insurance company D. the employer

A

Kevin and Nancy are married; Kevin is the primary breadwinner and has a health insurance policy that covers both him and his wife. Nancy has an illness that requires significant medical attention. Kevin and Nancy decide to legally separate, which means that Nancy will no longer be eligible for health insurance coverage under Kevin. Which of the following options would be best for Nancy at this point? A. COBRA B. apply for social security benefits C. apply for coverage under the same group policy that covers Kevin D. convert to an individual policy with 31 days so she won't have to provide evidence of insurability

A dependents of employees are eligible to receive group health insurance under the employee's plan. If the employee and dependent legally separate, the dependent will be eligible for COBRA benefits for up to 36 months.

What is the no-loss/no-gain statue?

It involves the theory of indemnification and the concept of placing the insured in the same economic position after loss as they were before. When changing, benefits must be paid for ongoing claims regardless of pre-existing condition.

What is a Multiple Employer Trust? In your answer describe the general circumstances of the people/groups who tend to compromise METs.

a MET is made up of individuals or small groups of individuals who do not qualify for group insurance

An employee insured under a group health plan has been paying $25 monthly premium for his group health coverage. The employer has been contributing $75, for the total monthly cost of $100. If the employee leaves the company, what would be his maximum monthly premium for COBRA coverage? A. $102 B. $25 C. $25.50 D. $100

A the employer is permitted to collect a premium from the terminated employee at a rate of no more than 102% of the original group premium rate

All of the following statements describe a MEWA EXCEPT A. MEWA employees retain full responsibility for any unpaid claims B. MEWAs can be self-insured C. MEWAs are group of at least 3 employers D. MEWAs can be sponsored by insurance companies

C at least 2 employers

Jason is insured under his employer's group health insurance. He splits the cost of the premiums with his employer. This is an example of a. half and half plan b. co-pay plan c. contributory plan d. noncontributory plan

c

Distinguish between contributory and noncontributory plans.

contributory plans are when employees are required to contribute to the payment of a premium; it must have at least 75% of employees participating. noncontributory plans are when participants do not pay the premium, the employee covers it all; 100% of all eligible employees must be included.

According to the Coordination of Benefits (COB) provision, if both parents have coverage where they are employed, under whom will the children be covered?

if both parents name their children as dependents under their group policies, the order of payment will usually be determined by the birthday rule: the coverage of the parent whose birthday is earliest in the year will be considered primary.