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

A large group consists of

51 or more people

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

60 days

Which federal law requires employers with more than 20 employees to include in their group insurance plan a continuation of benefits provision for all eligible employees?

COBRA

Which of the following is a federal law that requires employers with 20 ore more employees to allow former employees and their dependents a continuation of benefits after a qualifying event has ended their coverage?

COBRA

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

EIRSA

Which of the following statements regarding experience versus community rating by group health insurance plans is CORRECT?

Experience rating is based on past and projected medical costs of the group

An employee is eligible to continue his health insurance under COBRA rules. Which of the following statements is CORRECT?

His coverage under COBRA will be identical to that which he has under his group plan

Angela's fiancé gets a job with an architectural firm of 20 employees. He obtains medical expense coverage through his employer's group plan. Angela and her fiancé marry, and he lists Angela as a dependent under his plan. She becomes pregnant. What coverage, if any, can she expect from her spouse's group policy?

Routine maternity care will be covered in full

A group of employers from a similar industry assembled to qualify for group health insurance is

a multiple employer trust

John's Sports Store, Sam's Basketball Store, and Susan's Dance Studio join together to form a trust to provide insurance to their employees. This type of group is called

a multiple employer trust

Insurers usually allow a period of 30 or 31 days for employees to sign up for health insurance without having to prove evidence of insurability. This period of time is known as the

enrollment period

Underwriting for group health plans requires

no medical examination

Which of the following statements concerning a coordination of benefits provision is CORRECT?

the purpose of the coordination of benefits provision is to avoid duplication of benefit payment and overinsurance

After working 2 years with a competitor, Sergey immediately goes to work for MEP Company. Having been fully covered under his employer's group disability income plan, Sergey enrolls in his new employer's plan at his first opportunity to do so. As a new employee with MEP, when does the exclusion period for pre-existing conditions end?

there is no exclusion period

Under a group health insurance plan, a terminated employee may have which of the following options?

to convert the coverage to an individual plan at an adjusted premium

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

to expand coverage to many people that are uninsured

Which of the following employee populations may an employer legally exclude form group health benefits

union workers as a class

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

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

14 days

Under COBRA regulations, group health coverage of terminated employees must be continued up to

18 months

Under COBRA, the maximum period of coverage for termination of employment or a reduction in hours is

18 months

Dependent coverage for employees must be made available to a participating employee's spouse or children who are under age

26

Under the COBRA rules for employer group health insurance, which of the following statements is CORRECT?

Coverage may be continued for 36 months for a qualified beneficiary and 18 months for a terminated employee

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

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

Labor union plans are sponsored under

a Taft-Hartley Trust

A method of establishing the premium of a group based on the group's previous claim experience is known as

experience rating

A state law that requires benefits that began to be paid while a health insurance policy was in force to continue to be paid after the policy is terminated is known

extension of benefits

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

flow of members through the group

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

When an employer renew the group coverage with the same insurer year-to-year, this is known as

persistency

Tom and Gianna started working for ZZX Corporation on the same day. Tom does not enroll in the company insurance plan during the open enrollment period. What will Tom probably need to do?

Submit to a medical exam and full individual underwriting

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

63 days

According to HIPAA, a break in creditable coverage may not be

63 days or more

If a group insurance policy is contributory, what percentage of employees must participate?

75%

For group insurance policies, the covered individual receives proof of coverage in the form of

a certificate of coverage

What are members of a group health policy given that hows evidence of insurance?

a certificate of coverage

What doe the individual members of a group receive as evidence that they are covered by a group health insurance policy?

a certificate of coverage

A health insurance plan where the employees pay part of the cost and at least 75% of those eligible must participate in is known as

a contributory plan

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

a multiple employer welfare arrangement (MEWA)

The coordination of benefits provision provides that when a person is covered under more than one plan the

primary plan pays up to its limits first and then the secondary plan pays the rest

An insurer requirement that new employees must wait for a certain period of time before they can enroll in an employer's group health plan is called a(n)

probationary period

Marta is covered by 2 group health policies: one provided by her employer and the other provided by her spouse's employer. The coverage provided by her spouse's policy is called

secondary coverage

Mark is eligible for coverage on July 1. He enrolls on July 15. He does not need to take a medical exam because he enrolled within

the eligibility period

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

The premium cost for a group is based on

the experience rating

When both parents have employer-provided group coverage, which plan would be the primary payer that their children would be covered under?

the plan of the parent whose birthday falls earliest in a calendar year

In a group insurance contract, who controls the master policy?

the policyholder (owner)

Ahana was recently hired by a consulting firm. She must wait before she is eligible to enroll in the employer's group health insurance plan. This is known as

the probationary period

Sarah starts work at a new job on March 1. She is not eligible for insurance coverage until April 1. The period between the start date and her eligibility date is

the probationary period

The period of time an employee must wait before becoming eligible to enroll in an employer-sponsored health plan is called

the probationary period

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

The option to elect continuation of benefits after an employee's group plan is terminated expires

60 days after the individual receives notification

A lender, or creditor may sponsor a group health insurance plan for its group of debtors. This is known as

group credit disability insurance

What was the effect of the 1985 Consolidated Omnibus Budget Reconciliation Act (COBRA) on group health insurance plans?

it mandates that group health insurance coverage be extended for terminated employees for up to a specified period

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, bo more than 100% of a claim is paid