Unit 18 - Group Health Insurance

Natasha has paid $200 of her annual deductible through her employer's group health insurance policy. She recently went to the dermatologist and received a billing statement for $2,000. A week after her appointment, her employer replaces the group health plan with a different insurer, what will Natasha owe the dermatologist?

$1,800 When a group health insurance policy is replaced by another plan, the new insurer will allow deductibles paid under the old plan to count toward the new plan requirements. Since Natasha has only paid $200 toward her deductible, she will owe the difference between the medical expense and her deductible ($2,000 - $200 = $1,800).

For group health insurance, employees may be classified by all of the following EXCEPT

AGE Group health insurance participants may be classified by type of payroll, duties, and length of service, but not by age.

All of the following are requirements which were enacted as a result of HIPAA EXCEPT

ELIMINATING PRE-EXISTING CONDITIONS FOR ALL ELIGIBLE INDIVIDUALS HIPAA did not eliminate pre-existing conditions, however i placed limitations on how long they could be enforced. The Affordable Care Act eliminated pre-existing conditions when the law was passed in 2014.

Which of the following statements best describes the coordination of benefits provision of group medical expense policies?

IT PERMITS INSURERS COVERING A GIVEN INSURED TO COORDINATE BENEFITS SO THAT, AMONG ALL OF THEM, NO MORE THAN 100% OF A CLAIM IS PAID. When a person covered under 2 separate plans has a loss, the coordination of benefits provision coordinates the coverages of the policies so that no more than 100% of the medical expenses is paid.

Which of the following employers is NOT eligible for small employer group health insurance?

KALLIE, WHO OWN A HARDWARE STORE THAT EMPLOYS 55 FULL-TIME EMPLOYEES AND 12 PART-TIME EMPLOYEES Companies with fewer than 50 full-time employee are eligible for small group coverage. Part-time employees and independent contractors are not considered.

A qualifying event covers all of the following EXCEPT

MEDICAID ELIGIBILITY FOR THE COVERED EMPLOYEE A qualifying event covers Medicare, not Medicaid, eligibility; however, it covers all of the other items listed.

Which of the following statements regarding multiple employer trusts (METs) is NOT correct?

METs PROVIDE COVERAGE ONLY ON A SELF-FUNDED BASIS METs can provide benefits on a self-funded basis, or they can add benefits through a contract issued by an insurance company. In the latter case, the trust itself, rather than the subscribing employers, is the master contract holder.

Under COBRA regulations, which of the following statements regarding coverage of a spouse after divorce from an insured employee is CORRECT?

THE EX-SPOUSE'S COVERAGE CAN BE CONTINUED WITH IDENTICAL BENEFITS FOR A SPECIFIED PERIOD. Under COBRA, divorce is a qualifying event, and the ex-spouse can continue coverage identical to that provided before the divorce for up to 36 months. It may be possible for the ex-spouse to cover the policy, but the tis not a COBRA requirement. Although premiums may be increased, the terms of the coverage, including coinsurance and the deductible, must remain the same.

Which of the following is NOT a characteristic of group health insurance plans?

THE PARTIES TO A GROUP HEALTH CONTRACT ARE THE EMPLOYER AND THE EMPLOYEES The contract for coverage is between the insurance company and the employer, and a master policy is issued to the employer.

As it pertains to group health insurance, COBRA stipulates that

GROUP COVERAGE MUST BE EXTENDED FOR TERMINATED EMPLOYEES UP TO A CERTAIN PERIOD OF TIME AT THE EMPLOYEE'S EXPENSE COBRA requires employers with 20 or more employees to continue group medical expense coverage for terminated workers (as well as their spouses, ex-spouses, and dependent children) for up to 18 months (or 36 months, in some situations) following termination. However, the terminated employee can be required to pay the premium, which may be up to 102% of the premium that would otherwise be charged.

Eric works for J&G Corporation and is recently divorced. His 56-year-old ex-spouse, Sophie, wants to know if she can maintain coverage under Eric's group medical insurance plan. Which of the following statements best describes how this situation might be treated?

SOPHIE WOULD BE ABLE TO CONTINUE COVERAGE FOR UP TO 3 YEARS BY PAYING UP TO 102% OF THE PREMIUM REQUIRED FOR THE GROUP COVERAGE. If an employee's spouse becomes ineligible for coverage under the employee's medical policy because of divorce, the employer must offer coverage to the ex-spouse for up to 3 years, provided the ex-spouse notifies the employer within 30 days of her intent to continue coverage. She must also pay up to 102% of the applicable premium for the coverage.

Which of the following events would NOT terminate Brian's COBRA before the 18-month time limit?

THE FIFTH DAY HIS PREMIUM IS OVERDUE The qualifying events that can terminate COBRA coverage early are the day the individual becomes eligible for Medicare, has coverage under a new job, fails to pay the premium on the first day it is overdue, or on the day the employer ceases to maintain any group health plan.

Which of the following was the primary purpose of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)?

TO EXPAND COVERAGE ELIGIBILITY TO MANY PEOPLE THAT ARE UNINSURED HIPAA was sweeping legislation that expanded eligibility for coverage among many Americans. It also allowed individuals to continue their group health care coverage when leaving an employer.

Emily is 3 months pregnant and receiving prenatal health care from her employer group health plan. When her employer switches plans with a new insurer, Emily's claim with the original insurer

WILL BE CONTINUED FOR THE BALANCE OF HER PREGNANCY UNDER THE NO LOSS/NO GAIN RULE In many states a no loss/no gain statute requires that when either the employer or the insurer terminate a group plan, any employees receiving ongoing care under a claim must continue to be covered by the terminated plan for up to a year so they suffer no loss of coverage and care.

Prior to the Affordable Care Act, according to HIPAA, a newly hired worker was not subject to a waiting period fi she had less than how many days between jobs with no health insurance coverage?

63 DAYS HIPAA required a new employee to provide the employer (and insurer) with a letter of creditable coverage, attesting to the fact that there were no more than 63 days between prior coverage and new coverage. The purpose was to eliminate pre-existing condition exclusions. Upon the passing of the Patient Protection and Affordable Care Act (PPACA), health plans can no longer carry exclusions for pre-existing conditions.

Prior to the Affordable Care Act, according to HIPAA, a newly hired worker was not subject to a waiting period if she had less than how many days between jobs with no health insurance coverage?

63 DAYS HIPAA required a new employee to provide the employer (and insurer) with a letter of creditable coverage, attesting to the fact that there were no more than 63 days between prior coverage and new coverage. The purpose was to eliminate pre-existing condition exclusions. Upon the passing of the Patient Protection and Affordable Care Act (PPACA), health plans can no longer carry exclusions for pre-existing conditions.

For group health insurance, employees may be classified for eligibility purposes by all of the following EXCEPT

65 OR OLDER OR UNDER AGE 65 All employees that are eligible can enroll regardless of their age, handicaps, or sex. Employers can establish basic employment criteria. The employee must be: full-time, and activity at work that is, not on disability leave or other inactive status. Employers may also exclude union workers as a class, since their compensation and benefits are covered by a collective bargaining agreement.

Emily is 3 months pregnant and receiving prenatal health care form her employer group health plan. When her employer switches plans with a new insurer, Emily's claim with the original insurer

WILL BE CONTINUED FOR THE BALANCE OF HER PREGNANCY UNDER THE NO LOSS/NO GAIN RULE In many states a no loss/no gain statute requires that when either the employer or the insurer terminates a group plan, any employees receiving ongoing care under a claim must continue to be covered by the terminated plan for up to a year so they suffer no loss of coverage and care.

Which of the following criteria used in group health insurance underwriting reduces the risk of adverse selection?

FLOW OF MEMBERS THROUGH THE GROUP Employees being hired and employees leaving have all different health concerns, including none at all! By having such a continually diverse pool, the insurer is never at risk of insuring only employees with health problems.

All of the following are underwriting criteria for group health insurance EXCEPT

GEOGRAPHIC LOCATION OF THE GROUP Underwriting criteria includes the size and composition of the group, flow of members, plan design, payment for plans, persistency and administrative capability. The geographic location of the group is not part of the underwriting criteria.

All of the following are underwriting criteria for health insurance EXCEPT

GEOGRAPHIC LOCATION OF THE GROUP Underwriting criteria includes the size and composition of the group, flow of members, plan design, payment for plans, persistency and administrative capability. The geographic location of the group is not part of the underwriting criteria.

When an employee's coverage terminates under a group health policy, the employee has the option to elect continuation within

60 DAYS After an individual has received the eligibility notice for COBRA continuation from the employer, the option to elect coverage expires 60 days form the date of receipt.

Under Liz's group employer disability insurance, she is eligible to receive $1,500 every month. When she becomes disabled, she is also eligible to receive $850 each month from Social Security. How much will she receive each month from her group disability plan?

$650 Under the coordination of benefits provision of most group insurance policies, benefits paid by the group plan are reduced by any benefits received form social insurance plans, such as Social Security. Life will receive $850 from Social Security and $650 under her group plan, for a total benefit of $1,500.

Employers must provide notification statements to individuals eligible for COBRA continuation within

14 DAYS Notification must be provided within 14 days when a qualifying event occurs.

A single plan that covers the employees of two or more unrelated employers is called

A MULTIPLE EMPLOYER WELFARE ARRANGEMENT (MEWA) A MEWA is a plan that is established for the purpose of providing benefits such as health insurance to the employees of two or more employers.

Which of the following statements regarding the conversion privilege in group health insurance is CORRECT?

DURING THE PERIOD WHEN THE INSURED IS CONVERTING FROM THE GROUP TO THE INDIVIDUAL PLAN, SHE IS STILL INSURED. An insured employee who resigns or is terminated has 31 days in which to take out a conversion policy without having to show evidence of insurability. The insurer has the right to adjust the premium rate for the new policy. The insurance continues in force for the individual while she is converting form the group plan to an individual policy.

All of the following are requirements which were enacted as a result of HIPAA EXCEPT

ELIMINATING PRE-EXISTING CONDITIONS FOR ALL ELIGIBLE INDIVIDUALS HIPAA did not eliminate pre-existing conditions, however it placed limitations on how long they could be enforced. The Affordable Care Act eliminated pre-existing conditions when the law was passed in 2014.

Which of the following was enacted to protect the interests of participants in qualified benefit plans as well as group insurance plans?

ERISA ERISA laws protect the interest of participants in employee benefit plans as well as group insurance plans. COBRA extends group health coverage to terminated employees and their families. HIPAA protects the patient's right to privacy of information and the PPACA, also known as the Affordable Care Act, enacted health insurance reform.