Life- Chapter 13
High number of claims.
A small employer health benefit plan may be nonrenewed for all of the following reasons EXCEPT:
Guaranteed Coverage
Allows a new employee to enroll immediately without a waiting period if a certificate of creditable coverage is presented.
Conversion Privilege
Allows an employee to convert the group coverage to an individual policy, without proof of insurability, upon termination of eligibility or termination of the group plan, providing the request is submitted to insurer within 31 days after the qualifying event.
Eligibility for Coverage
An employee must be considered full time (min. 30 hrs/week) and must be actively at work before they can enroll in the group plan.
Business Group of One
An individual, sole proprietor, or a single full time employee of an S Corporation, C Corporation, Limited Liability Company, or partnership who has carried on business activities for at lease one year prior to app. date.
Small Employer
Any person, firm, corporation, partnership, or association that is actively engaged in business and has 50 employees or less.
Civil Rights Act/ Pregnancy Discrimination Act (PDA)
Applies to groups with 15 or more employees. Prohibits discrimination against women for pregnancy-related conditions.
ADEA (Age Discrimination in Employment Act)
Applies to groups with 20 or more employees. Forbids age discrimination against people who are 40+ years old. Provides that employers can't deny older workers.
Extension of Benefits
Covered individuals who are being treated for a medical condition must continue to have their claims covered.
Blanket Insurance
Covers a group of individuals whose membership changes frequently, such as students, passengers traveling on a common carrier, sports teams, volunteer firefighters, or other groups of people while being expose to a specific risk.
Products
Dental Vision Accident-Disability Short-Term Disability Long-Term Disability Critical Illness Insurance
Nonduplication and Coordination of Benefits
Determines primary and secondary coverage when an insured is covered by more than one group policy, and to help prevent overinsurance- having more than 100% of a claim paid.
Dependent Eligibility
Employee's spouse and all children from birth until age 26.
Coinsurance and Deductible Carryover
Employees must be fully credited with all expenses that have accumulated toward the annual deductible and/or out of pocket limit. Includes copayment for medications in companion or stand-alone prescription drug plans.
Multiple Employer Trusts (METs)
Entities formed by unrelated businesses in the same or related industrial classification.
Must be renewed unless:
Failure of the plan sponsor to pay premiums timely. Failure of sponsor to comply with a material provision. Plan sponsor committed fraud. Employer is no longer a member of the association. No covered employee that lives or works in service area.
Multi-Employer Welfare Associations (MEWAs)
Formed by larger employers for the purpose of obtaining more favorable rates for life and health insurance.
Admin. Capability
Group health plans handle many admin issues on behalf of the sponsor.
Nonoccupational injury or disease.
Group health plans usually cover:
Individual Plans and Eligibility
Guarantees that individuals who meet the eligibility requirements will have access to and will be bale to renew an individual health plan.
HIPAA
HIPAA was designed to provide coverage for people with preexisting conditions.
Eligible Employee
Has a regular work week (30 hours). Waiting period cannot exceed 90 days.
50 or less
How many employees would an employer require to be considered a small employer:
60 Days
How much time after a qualifying event has occurred and notice is given of their right to continue insurance does an employee or dependent have to elect continuation of the group health plan under COBRA?
Reinstatement for Military Personnel
If an employer discontinued health coverage during deployment, federal law requires an individual be allowed to resume plan membership without any type of waiting period as long as notice is given to the insurance company directly after your military deployment.
RELATIONSHIP WITH MEDICARE
If an individual is age 65 or over and continues to work, Medicare is usually secondary insurer.
Customer Groups
Include depositor, creditor, and debtor groups.
Advertising Requirements
Insurance companies responsibility for the accuracy of their personal testimonials.
Plan Design Factors
Insurer can require a min. % of the group to enroll in the plan to guard against adverse selection.
Medicare Carve-Out
Integrates an employer-sponsored plan with Medicare Parts A and B for retired employees.
Group Health Plans
Limit the ability of a new employer plan to exclude coverage for preexisting conditions.
Events that Terminate Coverage
May be terminated for an employee if employment is terminated, the employee no longer meets eligibility requirements or if the group contract is terminated.
Associations
Must have at the outset a min. number of members (usually 100) and is organized for a purpose other than buying insurance.
Must renew unless:
Nonpayment of required premiums. Fraud Noncompliance Insufficient employees Insurer cannot cancel for frequency of claims.
Requirements
Not be covered under any other health insurance plan. Not have prior coverage terminated due to nonpayment. Have 18 months creditable coverage with most recent coverage under an employer-sponsored plan. Have no more than a 63 day gap in coverage.
Pre-existing Conditions
Plan may impose a preexisting condition exclusion for that condition.
Risk Pools
Private, self-funded health insurance plans organized by a state to serve high-risk individuals who meet enrollment criteria and do not have access to group insurance.
Master Policy
Received by the group sponsor. Individual employees receive a Certificate of Insurance and a Summary of Benefits.
Persistency
Refers to the renewal quality of a plan and preventing it from lapsing due to nonpayment or being replaced.
No Loss-No Gain for Existing Claims and Pre-Existing Conditions
Requires that when a group health insurance is being replaced, ongoing claims under the former policy must continue to be paid under the new policy, overriding any preexisting conditions exclusion and establishing mandatory risk transfer.
CONTINUATION OF COVERAGE UNDER COBRA
States employers with 20 or more employees must provide a health coverage continuation option to all covered employees and dependents up to 18 months.
Labor Unions
The Taft-Hartley Act was an amendment to the National Labor Relations Act.
REPLACEMENT OF GROUP POLICIES
The agent should always provide a comparison of benefits between the present and the proposed plan of coverage.
Events that terminate COBRA coverage:
Timely premium payments are not made. Employer ceases to maintain any group health plan. Employee becomes eligible for Medicare benefits. Employee becomes eligible for any other group plan. Employee convers to individual plan.
Advertising
To give a complete and accurate description to the public, prevent unfair competition, and set a min. standard of conduct.
Open Enrollment Period
To help protect against preexisting conditions and immediate claims, group plans have a probationary period.
High Claim Frequency.
Under Small Employer Medical Expense Insurance, the insurer can nonrenew the health benefit plan for all of the following, EXCEPT:
WORKSITE PLANS
Voluntary benefit plans offered by insurance companies and premiums are withheld as payroll deductions by the employer.
Continuation of health insurance at the employee's expense for up to 18 months.
What benefit does COBRA provide to employees when an employee is terminated?
Utilize the group plan's conversion privilege.
What can an employee do in order to obtain coverage when they have a pre-existing condition and find out their job was just eliminated?
HIPAA
What law provides the right of employees to continue health insurance coverage when changing employers by removing any restrictions against waiting periods and coverage in a new group health plan, as long as the employee has had creditable coverage?
No Loss - No Gain Statutes
When group health insurance is being replaced, ongoing claims under the former policy must continue under the new policy, overriding any preexisting condition exclusion. This is a requirement under which of the following?
One individual.
When underwriting group life, the underwriter treats the group as if it were:
Adverse selection is not a concern for group contracts.
Which of the following is incorrect regarding the group underwriting process?
