Chapter 18
Level of benefits
A courier pro liking replacement coverage for hospital, medical, or surgical benefits on an expense-incurred or service basis in 60 days after the prior policy is this continued must call her all employees and dependents who wear a shirt under that prior policy when it was discontinued as long as they were eligible for coverage under that previous policy.
Pregnancy discrimination Act
Act of 1964 The law forbids discrimination in any aspect of employment which includes hiring, firing, pay, Job assignments, promotions, lay off, training, and Fringe benefit such as leave and health insurance.
Group life and disability
All policies of group life insurance, to all group disability policies come to any group non-prophet hospital service contract, and to Amy self insured valve for benefit plan issued in this state
Taxation of Group health benefits
And employer may deduct that amount paid for group plan as business expense. Employee contribution made on contributory are not tax deductible for the employee unless reimbursed medical expenses exceed 10% of the employee's adjusted annual gross income.
Cal COBRA
Applies to employers having 2 to 19 employees. If an employee was covered under cobra for 18 months he or she may be able to keep health insurers through Cal cobra for another 18 months.
Types of group coverage
Basic medical expense (hospital, surgical, and physicians expenses ),group major medical expense(comprehensive major medical policy or a supplemental major medical policy( can have different deductible initial, corridor integrated), coordination of benefits provision COB( that arrangement and health insurance to discourage multiple payments for this same plane under two or more policies).
Eligible for federal premium tax credits
Business with 25 or fewer employees may be a legible for federal premium tax credit as long as they purchase health insurance through the small business health options program(SHOP).
Definition of policy replacement
Carrier means the insurance company dependent shall have meaning set forth in the policy, discontinuance shall mean the termination of the policy, employee means all agents, extension of benefit means the continuation of coverage, policy means any group insurance policy group hospital service, policyholder means entity to which a policy or contract is issued, premium means consideration payable to the carrier, replacement coverage means benefits provided dead by SXC eating carrier, totally disabled shell have their meaning set fort in policy.
CIC 10128
Carrier meansThe insurance company, nonprofit hospital service Corporation, or other entity responsible for payment of benefits or Provision of service on there a policy.
COBRA
Consolidated Omnibus Budget reconciliation Act of 1985 and is federal statute that applies to employers offering group insurance who have 20 or more employees with in 31 days period. Employees have 60 days to elect a continuation of benefits under COBRA or the option is forfeited.
Blanket health insurance
Cover a group of individuals who are exposed to the same risk. For example,football team or owner of a campground.
Due Affordable Health care act (AHCA)
Dependents are allowed to stay on parents group policy until the age of 26, extend beyond 26 if that child is incapable of self-sustaining employment by reason of mentally disabled or physically disabled.
Probationary and eligibility period
Employee must work for an employer for some time to be qualified for enrollment on group insurance after 31 day period called eligibility period after probationary period.
ERISA
Employee retirement income security act of 1974 was intended to bring about quality in pension plans and maintaining both group health insurance and other qualified plans. Financial reports must be filed with the IRS and plan description must be filed with debt department of labor.
Contributory
Employees pay 25%and Employer pay 75% premium Premium for dependent can be paid by the employee
Non-contributory
Employer pays the entire premium 100% for policy
Cobra qualifying and extension
Employment is terminated for other than gross misconduct 18 months Read duction hours work Death of employee 36 months for dependent Dependent child no longer qualify as a dependent has aged out of the group plan. Employee enrollment Medicare, spouse and dependent child 36 months Divorce or legal separation of employment 36 months for former spouse.
Health insurance Portability and accountability act(HIPAA)
Enacted 1996 and affects almost all healthcare provider.law defines the information and client files belong to the client and must be protected. HIPAA is designed to make the health coverage more portable for individual who change job.
FMLA
Family and medical leave act in new parents including foster and adoptive parents may be eligible for 12 weeks of leave that may use for care of the new child.
Contributory and non-contributory
For group insurance employer must cover 100% of eligible employees with non-contributory plans. Contributory plans require 75% participation in order to avoid adverse selection for the insurer.
Conversion privilege
Group health plans providing medical expense coverage contain a conversion privilege for individuals who wish to convert the group to individual policy with the same insurer when they leave their employment during a 31 day period.
Policy replacement
Group life and disability, definitions, extension benefits, level of benefits.
Policy replacement by (CIC 10128)
Group life and disability, extension of benefits, level of benefits
GroupLife and disability
Group life insurance, all group disability policies, any group nonprofit hospital service contract, and any self insured Welfare benefit plan issued in this state.
Extension of benefits
Group policy which provide life insurance must extend the benefits for a reasonable time after the policy is discontinued for any employees who are totally disabled. Extend benefit for any condition causing total disability existing at the time of this continuance for at least 12 months after discontinuance.
Credit disability
Insurance is designed to provide monthly payments on an outstanding loan should the insured suffer a disability due to sicknesss or accident.
Master policy
Issued by sponsor in group policy for policy owner.
Who is the qualified for providing the group insurance
It must be natural groups, and have been in existence a certain period of time,usually two years.
Eligibility
Must be A true group in CA more than two or more than ten for other state. Must cover participant regardless of age or physical condition. Must employed full time for more than 90 days.
Health Coverage for newly hired employees
Need to pro why did if they previously had could get full coverage for 12 straight months with no lapse in coverage of 63 days or more. If the enrollee had creditable coverage for the last eight months, there would only be a four months exclusion. Lake enrollees in group health plans might have to wait up to 18 months for coverage for pre-existing condition.
Underwriting consideration
No medical information, carrier history, stability of the group, size and composition of the group, cost of care varies in different area, and length of waiting period for loss of time benefits.
Eligibility period
Normally a 31 days period after the probationary period ended .
Group accidental Death and dismemberment insurance(AD&D)
Occasionally it is offered to employees as separate policy for which the employees pay if they wish the additional coverage.
Category of disability income plants
Occupational (job-related )or non-occupational(not related to the job). Also Short term job related injury can cover by Worker's Compensation insurance.
Key employees
Officers the top 10 interest holders in the business.
Primary plan and secondary plan
One true or more group health insurance plans cover the insured and dependence, one plan will be considered the primary plan and the other considered secondary plan.
Third party administrator(TPA)
Outside organization used to administer the managerial and clerical functions related to multiple employer trust of self-insured employer plan .
AD&D principal sum and capital sum
Policies pay an additional sum if employee dies as the result of an accident. This song is referred to as the principal sum. If the employees suffers a dismemberment the policy pays a capital sum.
Multiple employer trust (METs)
Pro why benefits to employees of two or more financially related company and can have Lower costs.
Conversion privilege
Provide by group health plans employee can convert the group coverage to the individual policy when they leave their employment, during a 31 day period. During this conversion period the individual still is covered under the group policy whether or not exercising the conversion privilege.
Certificate of insurance
Received by individual covered under group policy.
Mental health parity and addiction equity act(MHPAEA)
Requires healthcare service plans that offer coverage for mental health or substance use disorders to provide the same level of benefits as are provided for general medical treatments. This does not require the plan to cover mental health and substance use disorders.
TEFRA
Tax Equity and Fiscal Responsibility Act of 1982 flies to employer's having 20 or more employees. TEFRA amends The Social Security act to make Medicare secondary to group health insurance plans
ADA
The Americans with disabilities act. ADA Apply to persons considered to have a physical or mental impairment that substantially limits one or more major life activities, Has a record of such an impairment or is considered to have such an improvement.
OBRA
The Omnibus Budget Reconciliation Act of 1989extended the minimum COBRA continuation of coverage from 18 to 29 months for qualified beneficiaries who where are disabled at the time of termination or reduction off work .
Group health insurance
The contract between the insurer and the sponsoring organization.
Deductible business expenses
The cost of insurance paid by an employer for employee benefits as it did octuple business expense on income tax return.
Cost of insurance paid by an employer for employee
The deductible business expense on income tax returns.
COBRA disqualification
The first day premium payment is not made on time The date the employer ceases to maintain group health insurance insurance. The date the individual becomes eligible for Medicare. The first day that an individual is covered under another group plan.
Groupdisability income plans
The payment amount normally is based on a percentage of the employees earnings such as 60%. This plan can be short-term (less tan 2yrs)or long-term (more than 2 yrs)disability plans.
Children coverage by both parents insurance
The primary insurance can be gender rule or the birthday rule. California uses the birthday rule which states that whichever parent's birthday comes first in the year is the primary insurer for the child.
Probation period
The time employees must work for employer usually is 90 days to sign up for group insurance .
Underwriting characteristics
Underwriting focus on the group as the whole Underwriting consideration by carrier history,the stsbility of the group, prior claims experience of the group, size and composition of the group, zip coad (the cost of care varies in different areas, and length of waiting period for the loss of time benefits.
Underwriting
Underwriting large for group policy focuses on the group as a whole.
Certificate of creditable coverage
When someone leaves a health plan he/she should get a certificate of creditable coverage.
Franchise Health insurance
Wholesale insurance to employees a small business, associations, and professional organization. There is no master contract issued to sponsoring organizations.
