group health insurance

small group coverage is for employers with

1 to 50 employees

a qualified association must provide health coverage to at least

1,000 employees and/or their dependents

Experience Rating

Group health insurance is usually subject to experience rating, where the premiums are determined by the experience of this particular group as a whole

Individual Employer Groups

Group health insurance plans may be purchased by individual employers, qualified associations, or licensed purchasing alliances to provide health care to employees and their dependents.

Group Contract

In group insurance the policy is called the master policy, and is issued to the policy owner, which could be the employer, an association, a union, or a trust.

community rating or pool rating

Individual policies are subject to ____________ ___________ where the premium is based upon the overall claims experience of the insurance company.

HIPAA

The Health Insurance Portability and Accountability Act is a federal law that protects health information

Insurer Underwriting Criteria

1.) Certificates are guaranteed issue with no individual underwriting 2.) Premiums are determined by age, sex and occupation of the entire group 3.) The reasons for forming the group are other than purchasing insurance 4.) A certain participation level must be maintained 5.) flow of new members 6.) everyone has the same coverage

large group coverage is available for employers with

51 or more employees

Self-funded programs

a non insured plan that uses a trust fund to pay for employees' health care expenses directly

a qualified association must meet the following requirements

1.) Have been in existence for at least 10 years prior to January 1, 1995 2.)Have the primary purpose other than providing health coverage 3.) Conduct regular meetings within the state, with the notice to all members at least 30 days prior to the date of any meeting

Annual Open Enrollment

30-day open-enrollment period is available once a year to employees who reject coverage during the initial enrollment period and later wish to have coverage or to add dependent coverage

Debtor

a borrower of funds

Creditor

a lender of funds

Certificate of Coverage

The individuals covered under a group insurance plan are issued evidence of coverage in the form of certificates of insurance, or certificates of coverage. The certificate of insurance cannot contain provisions or statements that are unfair, misleading or deceptive. 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.

Extension of Benefits

a provision that allows coverage to continue beyond the policy's expiration date for employees who are not actively at work due to disability or who have dependents hospitalized on that date (coverage continues only until the employee returns to work or the dependent leaves the hospital)

One of the differences between group underwriting and individual underwriting is that in groups of 50 or more,

medical information cannot be required of plan participants

Underwriting

risk selection and classification process

Employer Group Health Insurance

the group must be formed for a purpose other than obtaining group health insurance.There are generally 2 types of groups eligible for group insurance: employer-sponsored, and association-sponsored.

Adverse Selection

the tendency of poorer risks seeking out insurance protection.

Persistency

the tendency or likelihood of insurance policies not lapsing or being replaced with insurance from another insurer

Insurer Underwriting

the underwriter evaluates the group as a whole rather than each individual member. The group's risk profile determines whether the group will be accepted or rejected. As with any type of underwriting, the underwriter tries to avoid adverse selection