CH14 GROUP HEALTH AND BLANKET INS
what is the benefit of experience rating
It allows employers with low claims experience to get lower premiums [group health insurance is usually subject to experience rating where the premiums are determined by the experience of this particular group as a whole. experience rating helps employers with low claims experience bc they get lower premiums]
which is considered a qualifying event under COBRA?
divorce
which is NOT monitored by the ERISA?
golden parachutes [有pension, profit sharing, stock bonus, most health and life insurance]
what is the period of coverage for events such as death or divorce under COBRA
36 months
what is another name for an administrative-service only arrangement
3rd party administrator [an arrangement whereby an insurer agrees to provide certain services to a self-insured entity, such as providing printed claim forms, and the processing and auditing of claims, the insurer does not provide any insurance protection under an ASO arrangement]
which of the following factors would be an underwriting consideration for a small employer carrier
% of participation
which would be an underwriting consideration for a small employer carrier?
% of paticipation
one of the differences between group underwriting and individual underwriting is that there is little or no medical information required regarding plan participants in groups of
50 or more
To be acceptable to insurance companies, what percentage of eligible employees must be enrolled under a contributory group health insurance plan?
50%
If the insurance provided on an individual ceases because of termination of employment or of membership in the class eligible for coverage, the individual will be entitled to have an individual life policy issued without evidence of insurability, if application is made within what time period after termination?
60 days
All of the following are differences between individual and group health insurance EXCEPT
Individual insurance does not require medical examinations, while group insurance does require medical examinations
an association could buy group insurance for its members if it meets all of the following requirements EXCEPT -holds annual meetings -is contributory贡献的 -has at least 50 members -has a constitution and by-laws
C [must have 100 members]
in a group policy, the contract is between
Employer and the insurance company.
which acts provides an employee with 12 workweeks of leave to care during a 12-moth period to care for a son or daughter born to that employee?
FMLA family medical leave act
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?
COBRA [dependents of employees are eligible to receive group health insurance under the employee's plan. if the employee and the dependent become legally separated or divorced, or if the employee dies, the dependent will be eligible for COBRA benefits up to 36 months. This is best for Nancy, since she has endured a LT illness. Otherwise, being approved for individual health insurance would be difficult]
The main purpose of ERISA is to ensure that
Employees receive the pension and other benefits promised by their employers
what is the purpose of COBRA
To provide continuation of coverage for terminated employees [consolidated omnibus budget reconciliation act requires 20 or more employees to extend group health coverage to terminated employees and their families after a qualifying event]
which of the following groups seeking group health ins would represent a bad risk for underwritters?
a group that changes insurance annually
NY laws allows for which of the following groups to provide blanket accident and health ins -children at school -children at camp -volunteer fire department -all
all
Employees actively at work on the date coverage is transferred to another insurance carrier are
automatically covered and exempt from any probationary period
In cases where a covered employee is eligible for Medicare benefits to treat end stage renal disease with dialysis for kidney transplant, which of the following is correct? a) Medicare is primary for the first 12 months of treatment and then employer group insurance is secondary b) Medicare is the secondary payer during the first 30 months of treatment c) Medicare in the employer group insurance plan will share the cost equally d) Because Medicare does not cover treatment of ESRD the group plan will pay 100%
b -individuals eligible for medicare bc of end-stage renal disease ESRD and covered under the employer's group plan are primarily covered by the group health coverage for the first 30 months, then medicare would become the primary health provider
what types of benefit plan is a managed plan that is developed in conjunction with the health benefit plan committee?
basic coverage benefit plan [lower cost than standard bene plan]
The first street church plans to sponsor a summer camp for the youth of their congregation. They would like to purchase the insurance that would pay benefits should one of the youth get injured while participating in the camp activities. The type of policy they would likely need is a/an
blanket
which of the following options best depicts how the eligibility of members for group health insurance is determined
by conditions of employement [fulltime]
in order to be eligible for group health insurance, all of these are conditions an employee must meet EXCEPT -must be actively at work -must be a full-time employee -must have dependent -must be working in a covered classification
c
which of the following statements is NOT correct concerning the COBRA act of 1985 a. It applies only to employees with 20 or more employees that maintain group health insurance plans for employees. b. COBRA stands for consolidated omnibus Budjet Reconciliation Act. c. It requires all employees, regardless of the number or age of employees to provide extended group health coverage. d. It covers terminated employees and/or their dependents for up to 36 months after a qualifying event.
c [ONLY employers with 20 or more employees]
what type of benefit plan for group health insurance will provide coverage in the event of a catastrophic illness or injury
catastrophic care benefit plan
in NY , how must all medical expense health insurance sold to individuals or small groups be rates
community rated
if an employee terminates her employment, which of the following provisions would allow her to continue health coverage under an individual policy, if requested within 60 days
conversion
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 former employee's expense [20 or more, 18-36months, employee can be required to pay up to 102% of the coverage's premium]
welfare benefits include all of the following EXCEPT -health care benefits -workers compensation -holiday pay -day care benefits
holiday pay
who is the beneficiary in a credit health policy?
lending institution
regarding health insurance coverage for small groups, insurers are permitted to do any of the following EXCEPT
limited enrollment to a specific number [CAN limit enrollment to specific time periods, require people to work a certain number of hours to be classified as employees, and can limit changes to policies to be made only at established intervals
when compared with the administrative cost found in individual coverage, the percapita administrative cost in group health insurance is
lower
in group insurance, what is the policy called
master policy
Can a group that is formed for the sole purpose of obtaining group insurance qualify for group coverage?
no, the group must be formed for a purpose other than obtaining group insurance
Which renewal provision(s) must be included in a long-term care policy issued to an individual?
noncancellable and guaranteed renewable
a 55-year old employee has worked parti time for his new employer for 3 month now, but has not been offered health insurance. what factor has limited the employee's eligibility
number of hours worked per week
what type of policy contains a coverage that is only activated upon the insured's losses reaching a certain level?
partially funded insured plan [coverage is only activated upon the insured's losses reaching a certain level. it may take the form of maximum aggregate limit payable or a maximum limit payable for any one event]
which is an entity that can be hired by an employer to handle all its employee management tasks?
professional employer organization
if a firm has 50 employees at the point it applies for health coverage, what is its classification
smaller employer
the minimum number of persons to be insured under a group health insurance plan is established by
state law
which is monitored by EIRSA?
stock profit-sharing plans [cash bonus plans, cash profit sharing plans, and severance pay of less than two years are considered compensation and are not regulated by ERISA]
which of the following would be a qualifying event as it relates to COBRA
termination of employment due to downsizing
According to the Coordination of Benefits provision in health insurance in this state, if insurer overpaid on a claim, the insurer may recover the excess from all of the following EXCEPT -the person to whom the benefit has been paid -the insurance guaranty association -the other insurer -another organization involved in the claim
the IGA [CAN BE PAID by: person whole the benefits has been paid, insurance companies, other organization]
what type of information is NOT included in a certificate of insurance
the cost the company is paying for monthly premiums [what is covered, how to file a claim, how long coverage, how to convert the policy to an indi policy]
in a group policy, who is issued a certificate of insurance
the individual insured [the certificate tells what is covered in the policy, how to file a claim, how long the coverage will last, and how to convert the policy to an individual policy
Who guarantees a conventional fully-insured group plan?
the insurer/ ins comp [in return for the prem collected from the insured by the insurer, the insurer assumes the risk of paying the cost of medical expenses that may or may not occur during the policy period]
which state has jurisdiction over a group policy that covers individuals that reside in more than one state?
the state in which the policy was delivered [group insurance can often provide coverage for employees in more than one state. the state in which the coverage was delivered would have jurisdiction]
what is the purpose of a medicare carve-out or supplements医疗保险或补遗的目的是什么
they pay deductibles or copayments that are not paid by medicare
